Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-04051-287 | Vet Center Inspection of Continental District 4 Zone 2 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons administrative quality reviews were not completed, ensures completion, and monitors compliance.
Closure Date:
2 The District Director evaluates the administrative quality review report approval process to determine if a timeliness measure is needed and takes actions as indicated.
Closure Date:
3 The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.
Closure Date:
4 The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
Closure Date:
5 The District Director determines reasons for non-participation with the root cause analysis investigation for shared clients with the support Veterans Affairs medical facility and establishes processes to ensure required vet center participation.
Closure Date:
6 The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
8 The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
Closure Date:
9 The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
Closure Date:
13 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on mental health councils at Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
14 The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures 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 Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
16 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
17 The District Director determines reasons why completed trainings are not being recorded for employees at the Alexandria, Laredo, and Mesquite Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
18 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
Closure Date:
19 The District Director reviews reasons for noncompliance related to the Mesquite Vet Center’s emergency and crisis plan not containing all required components and ensures compliance.
Closure Date:
20 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Houston Southwest Vet Center and ensures all vet center employees safely and securely store personally identifiable information.
Closure Date:
| ||||
| 21-01805-286 | Vet Center Inspection of Pacific District 5 Zone 1 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons clinical quality review remediation plans were not completed, ensures completion, and monitors compliance.
Closure Date:
2 The District Director determines reasons administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
Closure Date:
3 The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.
Closure Date:
4 The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
Closure Date:
5 The District Director ensures the intake 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 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 why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
Closure Date:
8 The District Director ensures clinical staff consult and coordinate care with the support VA 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 verifies 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 confirms clinical staff make timely notification to the suicide prevention coordinator at the support Veterans Affairs medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff consult with the Vet Center Director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required, and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
Closure Date:
13 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Central Oregon Vet Center and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
14 The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Bellingham Vet Center, takes action to ensure requirements are met, and monitors compliance.
Closure Date:
15 The District Director determines reasons the Bellingham Vet Center did not have a written crisis plan, ensures requirements related to crisis plans are met and monitors compliance.
Closure Date:
16 The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Tacoma Vet Center, ensures assignment of a liaison, and monitors compliance.
Closure Date:
17 The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures Vet Center Directors implement processes, and monitors compliance.
Closure Date:
18 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
19 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
20 The District Director determines reasons employees at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
21 The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Wasilla Vet Center and ensures all exterior grounds are in good repair.
Closure Date:
22 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
Closure Date:
23 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Bellingham and Tacoma Vet Centers and ensures all vet center employees safely and securely store protected health information.
Closure Date:
| ||||
| 21-00268-273 | Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and ensure that staff use the VA Inter-Facility Transfer Form or an equivalent note to document inter-facility transfers.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring physicians record all required elements in the electronic health record prior to patient transfers.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
| ||||
| 21-00266-281 | Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System in West Haven | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Performance Improvement Committee meetings.
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 System Director evaluates and determines additional reasons for noncompliance and maintains a current written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
4 The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
5 The System Director and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that referring physicians identify the receiving physicians on the Inter-Facility Transfer Form or facility-defined equivalent note.
Closure Date:
6 The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure nurse-to-nurse communication occurs during the inter-facility transfer process.
Closure Date:
7 The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
8 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
| ||||
| 21-00272-283 | Comprehensive Healthcare Inspection of the West Palm Beach VA Medical Center in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all core members consistently attend Surgical Work Group meetings.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
| ||||
| 20-03407-253 | VA’s Management of Land Use under the West Los Angeles Leasing Act of 2016: Five-Year Report | Audit | ||
1 Implement a plan that brings the five new noncompliant land use agreements into compliance with the West Los Angeles Leasing Act of 2016, the draft master plan, and other federal laws, allowing reasonable time to correct deficiencies noted in this report.
2 Ensure VA’s capital asset inventory accurately reflects all land use agreements lasting six months or longer on the West Los Angeles campus.
Closure Date:
| ||||
| 21-00553-285 | Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois | Hotline Healthcare Inspection | ||
1 The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.
Closure Date:
2 The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.
Closure Date:
3 The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.
Closure Date:
4 The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.
Closure Date:
5 The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.
Closure Date:
6 The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.
Closure Date:
7 The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.
Closure Date:
8 The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.
Closure Date:
9 The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.
Closure Date:
10 The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.
Closure Date:
11 The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.
Closure Date:
12 The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.
Closure Date:
13 The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.
Closure Date:
14 The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.
Closure Date:
15 The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.
Closure Date:
| ||||
| 21-01304-275 | Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina | Hotline Healthcare Inspection | ||
1 The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
Closure Date:
2 The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
Closure Date:
3 The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
Closure Date:
4 The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
Closure Date:
5 The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
Closure Date:
6 The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.
Closure Date:
| ||||
| 20-01910-244 | Contracting Officer Warranting Program Meets Federal Requirements but Could Be Strengthened | Review | ||
1 The OIG recommended the executive director of the Office of Acquisition and Logistics assess the warrant justification template and determine whether additional information and guidance should be required.
Closure Date:
2 The OIG recommended the executive director of the Office of Acquisition and Logistics determine whether any additional formalized procedures to monitor contracting officer workload should be implemented and required throughout VA.
Closure Date:
3 The OIG recommended the executive director of the Office of Acquisition and Logistics identify updates to warrant program policies that can increase the consistency of standards and practices across VA to promote fairness and stringency of warrant requirements.
Closure Date:
| ||||
| 21-00261-266 | Comprehensive Healthcare Inspection of the VA Boston Healthcare System in Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee completes a final review of each case within 120 calendar days from the determination that a peer review is needed or approves a written extension request.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that emergency department and urgent care center staff screen patients for suicide risk using the Columbia-Suicide Severity Rating Scale.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and establishes a written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
5 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate patient transfers.
Closure Date:
6 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note, that includes all required elements, in the electronic health record prior to patient transfers.
Closure Date:
7 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to the receiving facility during inter-facility transfers.
Closure Date:
8 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure that nurse-to-nurse communication occurs as part of the inter-facility transfer process.
Closure Date:
| ||||
15039