Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-02993-181 | Deficiencies in the Mental Health Care of a Patient who Died by Suicide and Failure to Complete an Institutional Disclosure, VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director ensures completion of suicide risk screening and evaluation in accordance with Veterans Health Administration requirements.
Closure Date:
2 The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff collaboratively develop and update safety plans with patients to reflect the patient’s current risk and protective factors.
Closure Date:
3 The VA Southern Nevada Healthcare System Director ensures adherence to Veterans Health Administration requirements and VA Southern Nevada Healthcare System Standard Operating Procedure 116-14, Suicide Prevention Daily Operations, October 2019, in the consideration of high risk for suicide patient record flags.
Closure Date:
4 The VA Southern Nevada Healthcare System Director evaluates substance use disorder diagnostic and treatment referral processes for patients on the Inpatient Mental Health Unit and takes action as warranted.
Closure Date:
5 The VA Southern Nevada Healthcare System Director reviews current practices to ensure Inpatient Mental Health Unit staff reconcile and incorporate critical clinical information into treatment and discharge planning.
Closure Date:
6 The VA Southern Nevada Healthcare System Director expedites the establishment of mental health treatment coordinator policy in accordance with Veterans Health Administration requirements.
Closure Date:
7 The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff coordinate discharge plans with outpatient treatment providers, in accordance with Veterans Health Administration requirements.
Closure Date:
8 The VA Southern Nevada Healthcare System Director ensures patient complaints and requests are addressed in accordance with Veterans Health Administration requirements.
Closure Date:
9 The VA Southern Nevada Healthcare System Director promotes leaders’ accurate identification of sentinel events consistent with The Joint Commission definition and Veterans Health Administration requirements.
Closure Date:
10 The VA Southern Nevada Healthcare System Director conducts a full review of the patient’s
care, determines whether an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
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| 20-01807-173 | Adaptive Sports Grants Management Needs Improvement | Review | ||
1 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop standard operating procedures for all processes related to managing the adaptive sports grants program.
Closure Date:
2 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop and train current staff and identify and hire staff specialized in grants management.
Closure Date:
3 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish and execute a plan to evaluate risks posed by grant applicants before awarding grants, in accordance with VA financial policy.
Closure Date:
4 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish procedures to ensure the timely reimbursement of grant recipient expenses.
Closure Date:
5 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish grant closeout procedures that include communicating timelines with the grant recipients, documentation requirements for proper grant closeout, availability of grant funds, and a process to approve modification and extension requests.
Closure Date:
6 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director act to ensure all adaptive sports grants are closed out on time.
Closure Date:
7 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director determine, in coordination with VA’s Office of Finance and Office of General Counsel, whether a Purpose Statute violation occurred, whether account adjustments need to be made, whether Antideficiency Act violations occurred, and report any Purpose Statute and Antideficiency Act violations.
Closure Date:
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| 20-01257-180 | Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety and Value Council’s recommended improvement actions are fully implemented and monitored.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Utilization Management Committee’s recommended improvement actions are fully implemented.
Closure Date:
3 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that root cause analyses include all required review elements.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures all root cause analysis actions are fully implemented.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of aberrant drug-related behaviors prior to initiating long-term opioid therapy.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing as recommended for patients on long-term opioid therapy.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct follow-up assessments that include adherence to the pain management plan of care and effectiveness of the interventions.
Closure Date:
10 The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
Closure Date:
11 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete life-sustaining treatment decisions progress notes prior to hospice referrals.
Closure Date:
13 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Women Veterans Health Committee meetings.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders.
Closure Date:
15 The Deputy Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures standard operating procedures are kept up-to-date and reviewed at least every three years.
Closure Date:
16 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Endoscopy Clinic clean storage room maintains the required relative humidity range.
Closure Date:
17 The Deputy Director for Patient Care Services determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
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| 20-01256-179 | Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain a licensed healthcare professional’s first- or second-line supervisor completes provider exit review forms within seven business days of professionals’ departure from the medical center.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five suicide prevention outreach activities per month.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all staff complete annual suicide prevention refresher training.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners complete life-sustaining treatment decision progress notes.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that processes and procedures are in place for 24 hours a day, 7 days per week Emergency Department and medical center call coverage for gynecologic care.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
Closure Date:
8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
Closure Date:
10 The Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that align with medical center standard operating procedures prior to reprocessing reusable medical equipment.
Closure Date:
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| 20-00716-177 | Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
Closure Date:
2 The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
Closure Date:
3 The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
Closure Date:
4 The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
Closure Date:
5 The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
Closure Date:
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| 20-03229-155 | VBA Overpaid Veterans Due to Delays in Reducing Compensation Benefits | Review | ||
1 Establish, document, and implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments.
Closure Date:
2 Develop, document, and implement a formal procedure to routinely monitor the workload management strategy to ensure it minimizes delays and excessive payments.
Closure Date:
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| 20-01930-183 | Training Deficiencies with VA’s New Electronic Health Record System at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health explores the establishment of a group of Veterans Health Administration staff comprised of core user roles with expertise in Veterans Health Administration operations and Cerner electronic health record use with data architect level knowledge to lead the effort of generating optimized Veterans Health Administration clinical and administrative workflows.
Closure Date:
2 The Deputy Secretary establishes an electronic health record training domain that ensures close proximation to the production environment and is readily available to all end users during and following training.
Closure Date:
3 The Deputy Secretary ensures end users receive training time sufficient to impart the skills necessary to use the new electronic health record prior to implementation.
Closure Date:
4 The Deputy Secretary ensures the user role assignment process addresses identified facility leaders and staff concerns.
Closure Date:
5 The Deputy Secretary ensures Cerner trainers and adoption coaches have the capability to deliver end user training on Cerner and Veterans Health Administration electronic health record software workflows.
Closure Date:
6 The Deputy Secretary evaluates the process of super user selection and takes action as indicated.
Closure Date:
7 The Deputy Secretary reviews the Office of Electronic Health Records Modernization’s performance-based service assessments for Cerner’s execution of training to determine whether multiple, recurrent concerns are being accurately captured and addressed.
Closure Date:
8 The Deputy Secretary oversees the revision of an Office of Electronic Health Records Modernization training evaluation plan and ensures implementation of stated objectives.
Closure Date:
9 The Deputy Secretary reviews the Electronic Health Record Modernization governance structure and takes action as indicated to ensure the Under Secretary for Health’s role in directing and prioritizing Electronic Health Record Modernization efforts is commensurate with the Veteran Health Administration’s role in providing safe patient care.
Closure Date:
10 The Under Secretary for Health establishes guidelines and training to capture new electronic health record-related patient complaints, including patient advocacy.
Closure Date:
11 The Under Secretary for Health ensures an assessment of employee morale following implementation of a new electronic health record and takes action as indicated.
Closure Date:
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| 20-03704-165 | Inadequate Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations | Audit | ||
1 Establish procedures at all facilities with affiliated nonprofit corporations to help ensure VA medical center Research and Development Budget Office staff review nonprofit corporation invoice documentation and confirm services were performed before approving payment.
Closure Date:
2 Establish procedures for Research and Development Budget Office supervisors at all the VA medical centers with affiliated nonprofit corporations that ensure periodic reviews are conducted of invoices authorized for payment, confirming that staff verified services were performed before approving payments.
Closure Date:
3 Ensure the Nonprofit Program Office invoice review procedures incorporate verification that affiliated nonprofit corporations include evidence that services were provided with invoices submitted to VA.
Closure Date:
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| 20-03185-151 | Unreliable Information Technology Infrastructure Cost Estimates for the Electronic Health Record Modernization Program | Audit | ||
1 Ensure an independent cost estimate is performed for program life-cycle cost estimates related to information technology infrastructure costs.
Closure Date:
2 Reassess the cost estimate for Electronic Health Record Modernization program-related information technology infrastructure and refine as needed to comply with VA’s cost-estimating standards.
3 Develop procedures for cost-estimating staff that align with VA cost-estimating guidance.
4 Ensure costs for all information technology infrastructure upgrades funded by the Office of Information and Technology and the Veterans Health Administration or other sources needed to support the Electronic
5 Formalize agreements with the Office of Information and Technology and the Veterans Health Administration identifying the expected contributions from each entity toward information technology infrastructure upgrades in support of the Electronic Health Record Modernization program.
6 Establish procedures that identify when life-cycle cost estimates should be updated and ensure those updated estimates are disclosed in the program’s congressionally mandated reports.
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| 20-01265-172 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 10: VA Healthcare System Serving Ohio, Indiana and Michigan in Cincinnati | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the credentials files of physicians who had a potentially disqualifying licensure action are reviewed with Regional Counsel, or a designee, and submitted for approval of VA appointment.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and appoints a Veterans Integrated Service Network lead women veterans program manager.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead women veterans program manager provides quarterly program updates to executive leaders.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead women veterans program manager completes annual site visits at each facility within the Veterans Integrated Service Network.
Closure Date:
5 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
Closure Date:
6 The Network Director determines the reasons for noncompliance and makes certain that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
Closure Date:
7 The Network Director determines the reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead oversees facility development of corrective action plans within the required time frame and tracks action items until closure.
Closure Date:
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15160