Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00815-232 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.
Closure Date:
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| 21-02326-233 | Community Care Coordination Delays for a Patient with Oral Cancer at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas | Hotline Healthcare Inspection | ||
1 The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
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2 The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
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3 The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.
Closure Date:
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| 22-00404-207 | VBA Could Improve the Accuracy and Completeness of Medical Opinion Requests for Veterans’ Disability Benefits Claims | Review | ||
1 Implement electronic system enhancements to require claims processors to identify relevant evidence before a medical opinion request can be submitted.
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2 Enhance mandated training for all claims processors on making medical opinion requests and demonstrate progress showing that the training is achieving its intended impact.
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3 Strengthen monitoring controls by improving the national and local quality review processes to identify medical opinion request areas in need of improvement and demonstrate progress toward ensuring compliance with established procedures.
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| 22-00208-221 | Financial Efficiency Review of the VA Cincinnati Healthcare System | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
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2 Require the finance office to perform quarterly compliance reviews of pharmacy invoice reconciliations.
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3 Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
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4 Ensure the healthcare system submits Medical/Surgical Prime Vendor–Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
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5 Ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance concerns and challenges.
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6 Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
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7 Develop and implement a plan to increase inventory turnover to the Veterans Health Administration‑recommended level.
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8 Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
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| 22-00814-230 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2021 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures healthcare providers inform patients and/or caregivers when a medication is not FDA-approved; provide the option to refuse the medication; and advise them of the known risks, benefits, and alternatives prior to administration.
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| 21-03061-209 | Improved Processing Needed for Veterans’ Claims of Contaminated Water Exposure at Camp Lejeune | Review | ||
1 Centralize all Camp Lejeune-related claims processing at the Louisville VA Regional Office, or implement a plan and report progress mitigating the error rate disparity between the Louisville Regional Office and other regional offices.
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2 Conduct and report to the Office of Inspector General the results of targeted quality reviews of Camp Lejeune-related claims from all regional offices processing these claims until the accuracy rate meets or exceeds the Veterans Benefits Administration’s overall national accuracy goal for disability compensation claims.
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| 21-03595-219 | Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California | Hotline Healthcare Inspection | ||
1 The VA Greater Los Angeles Health Care System Director confirms that a process is in place to ensure community living center staff have knowledge of policies pertaining to nursing practice and documentation in the community living center.
Closure Date:
2 The VA Greater Los Angeles Health Care System Director ensures all nursing staff assigned to the community living center have received training on the completion and documentation of all required elements for pain assessments.
Closure Date:
3 The VA Greater Los Angeles Health Care System Director verifies that community living center nursing staff demonstrate knowledge of the procedure for managing verbal and telephone orders and monitors compliance.
Closure Date:
4 The VA Greater Los Angeles Health Care System Director reviews the Greater Los Angeles Healthcare System hand-off communication policy to determine if changes are warranted to
address the procedure for managing hand-offs, ensures understanding of policy by staff, and monitors compliance.
Closure Date:
5 The VA Greater Los Angeles Health Care System Director verifies that community living center staff are aware of events warranting submission of a Joint Patient Safety Report and how to submit one.
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6 The VA Greater Los Angeles Health Care System Director evaluates the circumstances surrounding the death of the resident and determines if peer reviews of relevant clinical staff are warranted.
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7 The VA Greater Los Angeles Health Care System Director ensures that community living center managers receive training on the types of reviews, including quality assurance and administrative investigations and when each is appropriate for use, and documents attendance.
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8 The VA Greater Los Angeles Health Care System Director ensures that actions identified in the Corrective Action Plan are tracked to completion.
Closure Date:
9 The VA Greater Los Angeles Health Care System Director confirms that an institutional disclosure is completed and documented to share that an “opportunity for intervention(transfer to the Emergency Department) existed and was considered but not acted on, prior to the terminal event.
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10 The VA Greater Los Angeles Health Care System Director directs community living center leaders to review policy and admission processes to ensure respiratory therapy equipment needed in the care of a resident is in place at the time of admission.
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| 21-01361-192 | The Compensation Service Could Better Use Special-Focused Reviews to Improve Claims Processing | Review | ||
1 Update the special-focused review standard operating procedure to require analysis of why errors occurred.
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2 Establish controls to ensure special-focused review reports communicate both benefit entitlement and procedural errors.
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3 Establish controls to ensure special-focused review reports communicate all errors identified at both the national and regional office levels.
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4 Implement a process to measure the effectiveness of actions taken in response to each special-focused review and determine whether a follow-up review is needed.
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5 Reassess special-focused review errors marked as “corrected” to determine whether corrective actions were taken.
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6 Assess whether an enhancement to the Quality Management System could mitigate the risk of claims processors closing special-focused review errors without correction and develop a process to ensure corrective actions are taken on all errors.
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| 21-02668-182 | Digital Divide Consults and Devices for VA Video Connect Appointments | Review | ||
1 Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.
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2 Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.
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3 Clarify timeliness goals for the digital divide consult, and video device order placement.
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4 Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.
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5 Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.
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6 Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.
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7 Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.
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8 Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.
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9 Augment tracking mechanisms for packages sent to patients to ensure VA receipt of the retrieval kit so that devices are accurately recorded in inventory and available for refurbishment and reissue.
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10 Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.
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| 21-02903-214 | Deficiencies in Life-Sustaining Treatment Processes at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews vulnerabilities related to life-sustaining treatment processes and do not resuscitate orders within Veterans Health Administration facilities
Closure Date:
2 The Michael E. DeBakey VA Medical Center Director evaluates staff’s reliance on the electronic health record as the definitive source for verification of life-sustaining treatment orders and patients’ code statuses and takes action as indicated
Closure Date:
3 The Michael E. DeBakey VA Medical Center Director ensures that corrective actions from internal and quality management reviews are fully developed, implemented, and monitored for effectiveness.
Closure Date:
4 The Michael E. DeBakey VA Medical Center Director ensures that the electronic health record displays life-sustaining treatment orders where staff can easily locate the information.
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5 The Michael E. DeBakey VA Medical Center Director ensures that modifications to patients’ life-sustaining treatment orders, including do not resuscitate orders, are confirmed with the
patient and surgical team and documented in the electronic health record prior to surgical procedures requiring anesthesia.
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6 The Michael E. DeBakey VA Medical Center Director determines that facility staff review patients’ code statuses for any changes upon patients’ return to units after surgical procedures.
Closure Date:
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15039