Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00533-157 | The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health reviews the processes by which COVID-19 emotional well-being resources were developed and disseminated and takes action as needed to increase and ensure Veterans Integrated Service Network and facility leadership as well as facility staff’s awareness of available resources about the potential risks and signs of burnout.
Closure Date:
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| 21-00296-145 | Comprehensive Healthcare Inspection of the VA New Jersey Health Care System in East Orange | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality Leadership Council.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends individual improvement actions, and clinical managers implement the committee’s recommendations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days from the date it is determined a peer review is required or have a written extension request approved by the Director.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits quarterly summaries of peer review data for review by the Executive Committee of the Medical Staff.
Closure Date:
5 The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets at least monthly.
Closure Date:
6 The Director evaluates and determines any additional reasons for noncompliance and ensures credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
7 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain all inter-facility transfers are monitored and evaluated as part of the Veterans Health Administration’s Quality Management Program.
Closure Date:
8 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
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| 18-04227-91 | Joint Audit of the Department of Defense and the Department of Veterans Affairs Efforts to Achieve Electronic Health Record System Interoperability | Special Review | ||
1 We recommend that the Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs review the actions of the Federal Electronic Health Record Modernization Program Office and direct the Federal Electronic Health Record Modernization Program Office to develop processes and procedures in accordance with the Federal Electronic Health Record Modernization Program Office charter and the National Defense Authorization Acts.
Closure Date:
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| 21-00300-130 | Comprehensive Healthcare Inspection of the Northport VA Medical Center in New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff conduct a peer review for all applicable deaths that occur within 24 hours of admission.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses at the time of initial application.
Closure Date:
3 The Associate Director for Patient Care Services determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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| 21-02125-132 | Purchases of Smartphones and Tablets for Veterans’ Use during the COVID-19 Pandemic | Review | ||
1 Establish a realistic goal for days in storage along with a process for closely monitoring days in storage and taking corrective actions when the goal is not met.
Closure Date:
2 Perform a cost-benefit analysis in conjunction with VA contracting officials and the contractor to determine whether a new process can be implemented that initiates the data plan when a device is issued to the veteran or otherwise reduces unused plan costs.
Closure Date:
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| 21-02209-147 | Inadequate Discharge Coordination for a Vulnerable Patient at the Portland VA Medical Center in Oregon | Hotline Healthcare Inspection | ||
1 The VA Portland Health Care System Director considers adding the requirement to document family contacts in patients’ electronic health records in Portland VA Medical Center Policy 11-11, Discharge Planning, and ensures that staff document contact with family members, including notification of discharge, when applicable.
Closure Date:
2 The VA Portland Health Care System Director ensures a review of the Emergency Department social worker’s care coordination of the patient and takes action as warranted.
Closure Date:
3 The VA Portland Health Care System Director considers requiring Privacy Office staff to communicate the specific missing element(s) when returning a release of information request.
Closure Date:
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| 21-00291-136 | Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete suicide safety plan training prior to developing suicide safety plans.
Closure Date:
2 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of VHA’s Quality Management Program.
Closure Date:
3 The Associate Director for Patient and Nursing Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
4 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required training.
Closure Date:
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| 21-01712-144 | Deficiencies in a Behavioral Health Provider’s Documentation and Assessments, and Oversight of Nurse Practitioners at the VA Pittsburgh Healthcare System in Pennsylvania | Hotline Healthcare Inspection | ||
1 The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment practices related to Patient 8’s suicide and homicide risk and Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment status; and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.
Closure Date:
2 The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment and documentation practices including suicide risk assessments, assessment of antipsychotic medication health factors and side effects, informed consent for off-label medication use, resolution of rule-out diagnoses, and use of copy and paste, and provides training as needed.
Closure Date:
3 The VA Pittsburgh Healthcare System Director aligns VA Pittsburgh Healthcare System Memorandum TX-154, Use of Psychopharmacologic Agents, December 20, 2018, with leaders’ expectations for the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed an antipsychotic medication.
Closure Date:
4 The VA Pittsburgh Healthcare System Director makes certain that behavioral health managers verify that all elements of the behavioral health nurse practitioner ongoing professional practice evaluation are reviewed.
Closure Date:
5 The VA Pittsburgh Healthcare System Director ensures a comprehensive review of managers’ oversight of behavioral health nurse practitioners’ ongoing professional practice evaluations and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.
Closure Date:
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| 21-02437-120 | Processing of Post-9/11 GI Bill School Vacation Breaks Affects Beneficiary Payments and Entitlement | Audit | ||
1 The acting under secretary for benefits updates the School Certifying Official Handbook and considers other training aids to ensure how to calculate and report vacation breaks is clearly detailed.
Closure Date:
2 The acting under secretary for benefits develops and implements procedures for claims examiners to verify that all consecutive days are included in enrollments flagged for manual processing containing reported vacation breaks in the remarks section.
Closure Date:
3 The acting under secretary for benefits obtains amended enrollments from school certifying officials to correct vacation break reporting errors identified during this review and take remedial action when appropriate.
Closure Date:
4 The acting under secretary for benefits applies data analysis and record matching to identify enrollments with possible vacation break reporting errors made by school certifying officials, or processing errors by claims examiners.
Closure Date:
5 The acting under secretary for benefits includes in the development of the new automated system fields for vacation breaks to eliminate the need for manual processing.
Closure Date:
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| 19-08364-140 | Facility Leaders’ Response to Inappropriate Mental Health Provider-Patient Relationships at the VA Illiana Health Care System in Danville, Illinois | Hotline Healthcare Inspection | ||
1 The Veteran Integrated Service Network 12 Director evaluates processes that affected facility supervisors’ initial efforts to identify and address facility mental health providers’ inappropriate relationships and takes actions as necessary.
Closure Date:
2 The VA Illiana Health Care System Director reviews the process for reporting providers to state licensing boards or state certification boards and makes appropriate changes as deemed necessary to ensure timely reporting.
Closure Date:
3 The VA Illiana Health Care System Director reviews Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted
Closure Date:
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15039