Recommendations
2156
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-03206-21 | Healthcare Facility Inspection of the VA Clarksburg Healthcare System in West Virginia | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff store clean and dirty equipment separately, repair torn furnishings, and keep the environment clean.
Closure Date:
2 Executive leaders ensure staff evaluate the cardboard backboards for pest concerns and reduce the risk of infection.
Closure Date:
3 Executive leaders ensure the facility’s policy for test result communication aligns with the VHA directive.
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| 23-02182-185 | Independent Audit Report of Pharma Logistics LLC’s Billing Compliance | Audit | ||
1 Confer with the Office of General Counsel regarding the potential recovery of the $4.4 million in manufacturer credits that were issued by manufacturers and retained by Pharma Logistics before the associated jobs were closed.
Closure Date:
2 Contact the Office of General Counsel regarding the potential recovery of unsupported discrepancies between the total credits received and amounts disbursed.
Closure Date:
3 Contact the Office of General Counsel regarding the potential recovery of unsupported return credits to manufacturers.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $4,138,382
Total: $4,138,382
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| 25-00199-19 | Healthcare Facility Inspection of the VA Tampa Healthcare System in Florida | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff have access to sinks or hand hygiene supplies in or near soiled utility rooms that store biohazardous materials.
Closure Date:
2 Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.
Closure Date:
3 Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.
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| 24-03420-18 | Healthcare Facility Inspection of the VA Sioux Falls Health Care System in South Dakota | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff post safety risk assessment permits for all construction projects.
2 The Director assigns a member of the executive leadership team as chair of the Construction Safety Committee to oversee safety activities.
Closure Date:
3 Executive leaders ensure staff install privacy curtains in all exam rooms.
4 Executive leaders ensure staff install handrails on both sides of the hallway in the Community Living Center.
Closure Date:
5 Executive leaders ensure staff follow the facility’s policy for communication of abnormal test results to patients.
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| 25-00192-15 | Healthcare Facility Inspection of the South Texas Veterans Health Care System in San Antonio | Healthcare Facility Inspection | ||
1 The Associate Director for Operations ensures staff keep patient care areas clean and clean storage areas free of dirty items and equipment.
Closure Date:
2 The Chief of Staff ensures the facility has workflows for all services to identify team members’ roles in the test result communication process.
Closure Date:
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| 25-00077-215 | Audit of Homeless Screening Clinical Reminder Process | Audit | ||
1 Ensure medical facilities establish and implement clear written Homeless Screening Clinical Reminder policies that define the roles and responsibilities of staff involved in the referral, follow-up, and monitoring processes.
2 Ensure medical facility staff involved in the Homeless Screening Clinical Reminder process are aware of and trained on written local policies and procedures for making referrals, conducting follow-up, and monitoring.
3 Develop and implement a review process to determine whether medical facility staff followed local Homeless Screening Clinical Reminder policies whenever a veteran does not receive a follow-up encounter within 30 days of a positive screening and correct any identified deficiencies.
4 Ensure all medical facilities have a reliable report that accurately lists veterans who screened positive and accepted referrals as well as the status of follow-up actions.
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| 25-01187-244 | Evaluation of Specimen Readings for Accuracy and Quality Assurance in the Laboratory at the John D. Dingell VA Medical Center in Detroit, Michigan | Hotline Healthcare Inspection | ||
1 The VA Detroit Healthcare System Director ensures pathology and laboratory medicine service leaders communicate feedback regarding staff-specific errors to facilitate staff learning and according to Veterans Health Administration high reliability organization guidance.
Closure Date:
2 The VA Detroit Healthcare System Director evaluates the quality and patient safety service response to patient safety events, including tracking and monitoring of service level corrective action plans to ensure timely resolution of patient safety events, and takes action as necessary.
Closure Date:
3 The VA Detroit Healthcare System Director verifies pathology and laboratory medicine service leaders demonstrate clear communication of the laboratory quality management technologist roles and responsibilities in accordance with Veterans Health Administration requirements.
Closure Date:
4 The VA Detroit Healthcare System Director ensures the pathology and laboratory medicine service will sustain oversight of manual complete blood count with differential reads for accuracy via retrospective pathologist secondary reviews.
Closure Date:
5 The VA Detroit Healthcare System Director makes certain that pathology and laboratory medicine service leaders track variance reporting and ensure completion of applicable corrective action in accordance with facility policy and Veterans Health Administration requirements.
Closure Date:
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| 25-01255-242 | Review of Veterans Health Administration’s National Teleradiology Program | National Healthcare Review | ||
1 The Director, National Teleradiology Program ensures guidance in memoranda of understanding, teleradiology service agreements, and policies related to the entity responsible for the completion of National Teleradiology Program radiologist peer reviews is consistent and aligns with Veterans Health Administration requirements.
2 The Director, National Teleradiology Program reviews the barriers, to include staffing shortages, to achieving turnaround time goals and creates a plan of action to optimize results.
3 The Director, National Teleradiology Program, in cooperation with Veterans Health Administration’s National Radiology Program, explores additional options for the recruitment and retention of National Teleradiology Program radiologists.
4 The Under Secretary for Health, in cooperation with Veterans Health Administration’s National Radiology Program, reviews the tools available for the recruitment and retention of radiologists across the Veterans Health Administration and creates a plan of action to optimize filling vacant positions.
5 The Under Secretary for Health ensures all facilities with an agreement for service by the National Teleradiology Program have a contingency plan.
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| 25-00206-14 | Healthcare Facility Inspection of the VA Altoona Healthcare System in Pennsylvania | Healthcare Facility Inspection | ||
1 The Executive Director ensures each service has a service-level workflow for test result communication.
Closure Date:
2 The Executive Director reviews current practices to obtain documents from community providers and determines if leaders can standardize an approach to improve timeliness.
Closure Date:
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| 25-00302-243 | Review of VISN 21 Clinical Resource Hub Sleep Medicine Physician Privileging | Hotline Healthcare Inspection | ||
1 The San Francisco Healthcare System Director confirms the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub sleep medicine licensed independent practitioners are privileged in accordance with policy and monitors for compliance.
2 The Sierra Pacific Veterans Integrated Service Network Director ensures Sierra Pacific Veterans Integrated Service Network leaders and San Francisco Healthcare System leaders are educated on Veterans Health Administration policies regarding actions required following licensed independent practitioners’ lapse in privileges.
Closure Date:
3 The Sierra Pacific Veterans Integrated Service Network Director confirms the San Francisco Healthcare System and the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub leaders complete a review of clinical care rendered by physicians with lapsed privileges as required by the Veterans Health Administration directive.
Closure Date:
4 The Under Secretary for Health ensures the Veterans Health Administration National Program Director, Sleep Medicine and the National Sleep Medicine Field Advisory Board review sleep medicine privileges and provide national guidance for sleep medicine physicians who seek other specialty privileges.
5 The San Francisco Healthcare System Director ensures that the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub director addresses sleep medicine physicians’ concern of potential for disruptions in sleep medicine services without dual privileges and notifies sites receiving Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub services if sleep medicine privilege changes will disrupt services.
Closure Date:
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15461