Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02489-69 | Inspection of Sterile Processing Services at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Carl T. Hayden VA Medical Center Director ensures that staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.
Closure Date:
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| 21-01507-61 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management 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 that facility providers complete aberrant behavior risk assessments on all patients prior to initiating long-term opioid therapy.
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers document justification for prescribing opioids and benzodiazepines concurrently.
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers communicate problematic urine test results to patients.
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers follow up with patients within three months after initiating opioid therapy to assess adherence to the pain management plan of care and effectiveness of interventions.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities monitor the quality of pain assessment and effectiveness of pain management interventions.
Closure Date:
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| 21-00497-46 | Audit of Community Care Consults during COVID-19 | Audit | ||
1 Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
Closure Date:
2 Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
Closure Date:
3 Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
Closure Date:
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| 20-00552-30 | VA’s Use of the Defense Logistics Agency’s Electronic Catalog for Medical Items | Review | ||
1 Update the Electronic Catalog Ordering Guide with additional guidance to clarify the requirement to consider Federal Supply Schedule contracts before ordering medical supplies and equipment through the Defense Logistics Agency’s Electronic Catalog and monitor compliance.
Closure Date:
2 Establish a process to monitor orders through the Defense Logistics Agency’s Electronic Catalog to identify recurring acquisitions that could be purchased through other contract vehicles at a lower price.
Closure Date:
3 Require a justification for every order through the Defense Logistics Agency’s Electronic Catalog if a Federal Supply Schedule contract is available.
Closure Date:
4 Correct and monitor compliance with the Rule of Two diagram in the Electronic Catalog Ordering Guide.
Closure Date:
5 Establish a process to ensure appropriate documentation and audits of orders in accordance with the Electronic Catalog Ordering Guide.
Closure Date:
6 Conduct and document annual reviews as required in the interagency agreement.
Closure Date:
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| 21-00236-44 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 8: VA Sunshine Healthcare Network in St. Petersburg, Florida | 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 Lead Women Veterans Program Manager completes yearly site visits at each facility within the Veterans Integrated Service Network.
Closure Date:
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| 21-00279-54 | Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure all patient transfers are monitored and evaluated.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring providers complete all required elements of the VA Inter-facility Transfer Form or facility-defined equivalent prior to patient transfers.
Closure Date:
3 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that Employee Threat Assessment Team members complete the required training.
Closure Date:
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| 20-03351-08 | MISSION Act Market Assessments Contain Inaccurate Specialty Care Workload Data | Audit | ||
1 The OIG recommended that the acting under secretary for health perform additional analyses to ensure materially accurate specialty care workload data are used to implement the Asset and Infrastructure Review Commission recommendations.
Closure Date:
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| 21-01804-56 | Vet Center Inspection of Pacific District 5 Zone 2 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons for missing and incomplete clinical quality reviews, remediation plans, and resolution of deficiencies; ensures completion; and monitors compliance.
Closure Date:
2 The District Director evaluates the process for resolution of clinical quality review deficiencies and initiates action as necessary.
Closure Date:
3 The District Director determines reasons for missing and incomplete administrative quality reviews, remediation plans, and resolution of deficiencies; ensures completion; and monitors compliance.
Closure Date:
4 The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.
Closure Date:
5 The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
6 The District Director ensures lethality risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including reasons completion dates are not visible in RCSnet and ensures compliance with standards for timely completion of intake assessments and lethality risk assessments.
Closure Date:
8 The District Director ensures clinical staff consult and coordinate care with the shared support VA medical facility for clients with high risk for suicide flag placement and monitors compliance across all zone vet centers.
Closure Date:
9 The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, or suicide prevention coordinator following a lethality status change as required and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director, in collaboration with the support VA medical facility clinical or administrative liaison, determines the reasons for noncompliance with staff participation on mental health councils at the Fresno, High Desert, Honolulu and Santa Cruz County Vet Centers, and takes action as required.
Closure Date:
13 The District Director determines reasons for noncompliance with completing and tracking the required four hours of external clinical consultation per month, ensures that Vet Center Directors have processes to track consultation hours, and monitors compliance at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers.
Closure Date:
14 The District Director determines reasons for noncompliance with staff supervision provided by the Vet Center Directors at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
15 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
16 The District Director determines reasons why trainings were not completed at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
17 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the High Desert, Honolulu, and Santa Cruz County Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards requirements.
Closure Date:
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| 21-00960-17 | Financial Efficiency Review of the Marion VA Medical Center in Illinois | Financial Inspection | ||
1 Develop a plan to routinely provide updates when changes in stock levels are anticipated and work with the prime vendor to address having adequate stock to meet orders.
Closure Date:
2 Ensure logistics staff and 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.
Closure Date:
3 Implement a process to routinely check the formulary for additions and update the ordering system to reflect the prime vendor as the source for purchasing newly added supplies.
Closure Date:
4 Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
Closure Date:
5 Ensure healthcare system finance office staff are made aware of policy requirements and the responsible finance office conducts reviews on all open obligations as required by VA Financial Policies and Procedures, vol. II, chap. 5, “Obligations Policy,” January 2018.
Closure Date:
6 Promote veterans’ use of the Consolidated Mail Outpatient Pharmacy.
Closure Date:
7 Educate non-VA providers on prescribing lower-cost drugs.
Closure Date:
8 Implement Veterans Integrated Service Network 15 recommendations to ensure the cost-saving initiatives are implemented, tracked, and monitored to achieve identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
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| 21-01038-49 | Deficiencies in a Patient’s Lung Cancer Screening, Renal Nodule Follow-Up, and Prostate Cancer Surveillance at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Medical Center Director reviews primary care and pulmonology processes to ensure patients with high-risk factors for lung cancer receive screening and follow-up care and monitors compliance.
Closure Date:
2 The VA Southern Nevada Healthcare System Medical Center Director implements processes to ensure that patients with abnormal radiology findings have appropriate follow-up and monitors compliance.
Closure Date:
3 The VA Southern Nevada Healthcare System Medical Center Director ensures that providers follow the guidelines for surveillance for patients who have undergone prostatectomy.
Closure Date:
4 The VA Southern Nevada Healthcare System Medical Director reviews primary care providers’ copy and paste practices, implements processes to ensure a current plan of care is documented in the electronic health record, and monitors compliance.
Closure Date:
5 The VA Southern Nevada Healthcare System Medical Center Director reviews the complaint reporting and responding processes, ensures complaints are addressed in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
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15039