Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00298-72 | Comprehensive Healthcare Inspection of the VA Hudson Valley Health Care System in Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the referring physician includes all required elements on the VA Inter-Facility Transfer Form or facility-defined equivalent note in the patient’s electronic health record.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff send pertinent medical records to the receiving facility during inter-facility transfers.
Closure Date:
5 The Associate Director for Patient Care Services determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required trainings.
Closure Date:
7 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:
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| 21-00276-67 | Comprehensive Healthcare Inspection of the Durham VA Health Care System in North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
3 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that inter-facility transfers are monitored and evaluated.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that appropriately privileged providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note, and document all required elements prior to patient transfers.
Closure Date:
5 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities.
Closure Date:
6 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Disruptive Behavior Committee documents patient notification for an Order of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
8 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete the assigned prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 21-00292-73 | Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Work Group meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent prior to patient transfer.
Closure Date:
4 The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
5 The Medical Center 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:
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| 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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15160