Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-01508-32 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Women's Health Care 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 each facility has processes and procedures in place for emergency care 24 hours per day, 7 days per week and facility call coverage for gynecologic care.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a women veterans program manager who is full-time and free of collateral duties.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a designated maternity care coordinator.
Closure Date:
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| 21-00913-267 | Systems and Tools Implemented to Track COVID-19 Vaccine Data | Review | ||
1 The OIG recommended the under secretary for health develop processes for verifying facility data entered on the Pharmacy Benefits Management Services’ SharePoint website (or any subsequent data collection tool) for vaccine supply and usage.
Closure Date:
2 The OIG recommended the under secretary for health develop a process to monitor the use of tools that have been fielded to standardize data entry for vaccine doses administered by VA medical facilities and clinics to minimize data entry errors, including the Computerized Patient Record System’s clinical reminder, the Occupational Health Record-keeping System 2.0’s guided data entry guidance, and reports that can be used to identify data entry errors in these systems, or in any subsequent systems that VA uses to collect data on vaccinations.
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3 The OIG recommended the under secretary for health make sure that the Power BI dashboard data are reliable, accurate, and complete, and capture all vaccine data more accurately for VA medical facilities in the same healthcare system.
Closure Date:
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| 20-00426-02 | VA Applications Lacked Federal Authorizations, and Interfaces Did Not Meet Security Requirements | Review | ||
1 Review the SaaS applications named in the allegation to determine whether VA staff are still using them and whether such use is consistent with VA policy. If use is authorized, implement controls to ensure the applications go through the Federal Risk and Authorization Management Program authorization process and the VA SaaS application approval process. If use is not authorized, implement controls to prevent employees from using the SaaS applications without authority to operate.
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2 Determine whether Federal Risk and Authorization Management Program authorization will be pursued for the IRBManager application. If the required federal authorization is not pursued, include this application in the annual certification letter to the Federal Chief Information Officer along with the appropriate rationale and proposed mitigation plan.
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3 Implement JavaScript Object Notation Web Encryption for Lighthouse application programming interfaces that transmit sensitive information and resource-sharing requirements for cross-origin resource sharing to meet the requirements of VA Office of Information Security’s Application Programming Interface Security Pattern. Alternatively, coordinate with the Office of Information Security to determine if modifications or exceptions to security standards are warranted.
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4 Implement alerts for application programming interface-related abuse to meet the requirements of the VA Office of Information Security’s Application Programming Interface Security Pattern.
Closure Date:
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| 20-04050-37 | Vet Center Inspection of Continental District 4 Zone 1 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines the reasons clinical and administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required and ensures compliance.
Closure Date:
2 The District Director evaluates the clinical and administrative quality review process for resolution of quality review deficiencies and initiates action steps as necessary.
Closure Date:
3 The District Director evaluates the clinical and administrative quality review report process for determining timeliness in resolving quality review site visit deficiencies and initiates action steps as necessary.
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4 The District Director determines the reasons critical incident quality reviews (currently known as mortality and morbidity review) for serious suicide attempts including analysis for corrective action were not completed, ensures completion, and monitors compliance.
Closure Date:
5 The District Director ensures the intake assessment portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
Closure Date:
6 The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
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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, military histories, and lethality risk assessments.
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8 The District Director ensures clinical staff consult and coordinate care with the support Veterans Affairs medical facility for shared clients flagged as high risk for suicide 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 shared support Veterans Affairs medical facility for shared clients who are flagged as 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.
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12 The District Director in collaboration with the support Veterans Affairs medical facility clinical or administrative liaison determines the reasons for noncompliance with staff participation on mental health councils at the Casper, Denver, and Midland Vet Centers, and takes actions to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
13 The District Director determines reasons an external clinical consultant was not assigned as required at the Midland Vet Center and ensures compliance.
Closure Date:
14 The District Director determines reasons for noncompliance with processes for completing and tracking four hours per month of external clinical consultation at the Casper, Denver, El Paso, and Midland Vet Centers, and ensures that Vet Center Directors implement processes and monitors compliance.
Closure Date:
15 The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that staff supervision occurs as required, and monitors compliance.
Closure Date:
16 The District Director determines reasons for noncompliance with monthly RCSnet chart audits at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that chart audits are completed as required, and monitors compliance.
Closure Date:
17 The District Director determines reasons for errors in training assignments for staff at the Casper, Denver, El Paso, and Midland Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
18 The District Director evaluates and determines reasons tactile (braille) signage was not posted at all exit doors at the Casper, Denver, El Paso, and Midland Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
Closure Date:
19 The District Director reviews the reasons an updated emergency and crisis plan was not available at the Denver and Midland Vet Centers and ensures an updated plan is accessible to all staff.
Closure Date:
20 The District Director reviews reasons for noncompliance with client record storage at the Denver, El Paso, and Midland Vet Centers and ensures all client records are stored as required.
Closure Date:
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| 21-01695-38 | Discharge Planning Deficits for a Veteran at the Malcom Randall VA Medical Center in Gainesville, Florida | Hotline Healthcare Inspection | ||
1 The Malcom Randall VA Medical Center Director reviews roles and responsibilities for interdisciplinary treatment team members and the process for communication of plans and recommendations from all clinical team members and takes action as indicated.
Closure Date:
2 The Malcom Randall VA Medical Center Director ensures clinical staff follow established policy to alert clinical team of pertinent care changes by using the additional signer functionality or other methods of communication.
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3 The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned occupational therapy provider involved in the discharge planning for the patient and takes follow-up action as indicated.
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4 The Malcom Randall VA Medical Center Director conducts a review of care rendered by the attending physician involved in the discharge planning for the patient and takes follow-up action as indicated.
Closure Date:
5 The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned social worker involved in the discharge planning for the patient and takes follow-up action as indicated.
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| 20-03700-35 | Delayed Cancer Diagnosis of a Veteran Who Died at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 The Raymond G. Murphy VA Medical Center Director ensures supervising providers oversee all clinical decisions made by residents and the oversight is reflected within the documentation, including telephone notes.
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2 The Raymond G. Murphy VA Medical Center Director ensures supervising providers establish a reliable way to receive alerts for the results of all tests ordered by residents.
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3 The Raymond G. Murphy VA Medical Center Director ensures that Primary Care and Specialty Care staff coordinate care for shared patients and evaluates the need for Outpatient Care Coordination Agreements.
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4 The Raymond G. Murphy VA Medical Center Director ensures that patient, family, or staff concerns regarding delay in diagnosis are entered into the patient safety reporting system and appropriate follow-up is completed.
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5 The Raymond G. Murphy VA Medical Center Director coordinates a comprehensive review of the patient’s care, takes action as warranted, and reconsiders an Institutional Disclosure.
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6 The Raymond G. Murphy VA Medical Center Director ensures consistency between the relevant prior radiological images reviewed when staff radiologists and contract teleradiologists interpret imaging scans for Raymond G. Murphy VA Medical Center patients.
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| 21-00235-13 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System in Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain to designate a mental health professional to serve on each state’s suicide prevention council or workgroup.
Closure Date:
3 The Network Director determines the reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to required Veterans Integrated Service Network leaders.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager conducts 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:
5 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager has Veterans Integrated Service Network-level support staff for data analysis and performance improvement projects.
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| 21-00434-233 | New Patient Scheduling System Needs Improvement as VA Expands Its Implementation | Review | ||
1 Continue to make improvements to the scheduling training as needed to address feedback from schedulers.
Closure Date:
2 Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed
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3 Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.
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4 Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.
Closure Date:
5 Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.
Closure Date:
6 Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.
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7 Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.
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8 Provide guidance to schedulers to consistently address system limitations until problems are resolved.
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| 20-01324-215 | DMLSS Supply Chain Management System Deployed with Operational Gaps That Risk National Delays | Review | ||
1 Director of the Office of Acquisitions, Logistics, and Construction: Ensure the VA Logistics Redesign office revisits its Defense Medical Logistics Standard Support system oversight and deployment processes to align them with VA’s acquisition program management framework requirements.
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2 Director of the Office of Acquisitions, Logistics, and Construction: Develop processes to better identify unmet high-priority business requirements and post-deployment challenges at the Captain James A. Lovell Health Care Center and future sites and to make certain that solutions are developed and implemented.
Closure Date:
3 Director of the Office of Acquisitions, Logistics, and Construction: Properly staff the VA Logistics Redesign office with personnel who possess the appropriate subject matter expertise and employ measures to improve continuity in the project management team that oversees the Defense Medical Logistics Standard Support system’s implementation.
Closure Date:
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| 20-03437-26 | Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
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2 The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
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3 The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
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4 The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
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5 The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.
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6 The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
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15039