Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00237-114 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 6: VA Mid-Atlantic Health Care Network in Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials files and approve the VA appointments of physicians who had potentially disqualifying licensure actions.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Veterans Integrated Service Network’s Emergency Management Committee meets at least quarterly.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Emergency Manager completes an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Lead Women Veterans Program Manager completes annual site visits at each facility within the Veterans Integrated Service Network.
Closure Date:
5 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Lead Women Veterans Program Manager completes assessments to identify staff’s women’s health education gaps and develops or adapts educational programs, materials, or resources where gaps are identified.
Closure Date:
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| 21-01503-112 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Medical Staff Privileging in Veterans Health Administration Facilities, Fiscal Year 2020 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that service chiefs include service-specific criteria in ongoing professional practice evaluations.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff recommend continuing licensed independent practitioners’ privileges based on professional practice evaluation results.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from a medical facility.
Closure Date:
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that provider exit review forms are signed by the service chief, the chief of staff, and the medical facility director if the licensed healthcare professional failed to meet the generally-accepted standards of care.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures credentialing and privileging managers initiate the state licensing board reporting process within the required time frame when licensed healthcare professionals fail to meet generally-accepted standards of care.
Closure Date:
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| 21-00510-105 | Improved Governance Would Help Patient Advocates Better Manage Veterans’ Healthcare Complaints | Audit | ||
1 Review and update, as appropriate, program policy to formally align with the Office of Patient Advocacy’s program expectations, including when complaints must be entered into a patient advocate tracking system and the responsibilities of patient advocate supervisors.
Closure Date:
2 Implement controls that require facility patient advocate supervisors and Veterans Integrated Service Network patient advocate coordinators to perform regular, documented reviews of records in the patient advocate tracking system to monitor that the required information is entered properly.
Closure Date:
3 Provide guidance to medical facility directors to ensure they fulfill their required Patient Advocacy Program management duties, including timely complaint resolution and trending complaint data.
Closure Date:
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| 21-00282-111 | Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all sentinel events.
Closure Date:
2 The Medical Center Director determines the reasons for noncompliance and ensures the Systems Redesign Manager participates on the Veterans Integrated Service Network Systems Redesign Review Advisory Group.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members regularly attend Surgical Workgroup meetings.
Closure Date:
4 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.
Closure Date:
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| 22-00879-118 | VA’s Compliance with the VA Transparency & Trust Act of 2021 | Review | ||
1 Consult with appropriate VA financial and legal officials to determine whether the use of CARES Act funds for the Beaufort National Shrine project violates the Purpose Statute and, if a violation occurred, take the steps necessary to remedy the violation.
Closure Date:
2 Determine the obligations to sustain essential information technology investments, update the obligation schedule as necessary, provide an updated spend plan to Congress, and include this information in future biweekly updates.
Closure Date:
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| 21-00656-110 | Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.
Closure Date:
2 The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.
Closure Date:
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| 21-00781-109 | Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.
Closure Date:
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| 21-00781-108 | Ticket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.
Closure Date:
2 The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.
Closure Date:
3 The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.
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| 21-00281-100 | Comprehensive Healthcare Inspection of the Salem VA Medical Center in Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that staff monitor and evaluate inter-facility patient transfers as part of VHA’s Quality Management Program.
Closure Date:
2 The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.
Closure Date:
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| 21-03325-86 | Review of Allegations of Improper Maintenance at VA’s Houston National Cemetery | Review | ||
1 Revise the equipment policy to include provisions and timelines to resume routine activities, such as required preventive maintenance checks, which could be affected by natural disasters or emergencies, such as the COVID 19 pandemic.
Closure Date:
2 Provide an action plan and timeline to repair the headstones or sod in the 65 gravesites the team identified.
Closure Date:
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15039