Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-02826-07 | Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams | Review | ||
1 Further develop, implement, and test its strategy to reduce the exam inventory using in person, telehealth, and acceptable clinical evidence exams as safety and circumstances permit.
Closure Date:
2 Develop and implement a plan to increase the use of telehealth exams. VBA should also ensure contractors follow the Office of Disability and Medical Assessment telehealth guidance for exams that determine whether a telepresenter or specific medical equipment is required.
Closure Date:
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| 19-08411-12 | Deficiencies in Ambulatory Care Center and Emergency Department Processes at the VA Loma Linda Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director ensures that mental health clinic nursing staff are trained on documentation requirements when providing patient care and monitors compliance with training.
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2 The VA Loma Linda Healthcare System Director reviews the facility’s hand-off communication policy to ensure that nursing staff are aware of all circumstances in which hand-off communication must occur and takes action as necessary.
Closure Date:
3 The VA Loma Linda Healthcare System Director ensures that all nurses filling the first look nurse role obtain and document each patient’s vital signs within 10 minutes of the patient’s arrival to the Emergency Department and monitors compliance.
Closure Date:
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| 20-00129-09 | Comprehensive Healthcare Inspection of the Atlanta VA Health Care System in Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, and Value Committee consistently reviews and integrates aggregated quality, safety, and value data.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures improvement actions recommended by the Quality, Safety, and Value Committee are fully implemented and improvement changes are monitored.
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3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date it is determined a peer review is required and, if necessary, extensions are approved in writing by the System Director.
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4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinical managers consistently implement improvement actions recommended from peer review activities.
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5 The System Director determines the reasons for noncompliance and ensures that root cause analyses include all required review elements.
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6 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within 45 days.
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7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
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8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete and document focused professional practice evaluation results in licensed independent practitioners’ profiles.
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9 The Chief of Staff determines the reasons for noncompliance and ensures that practitioners with similar training and privileges complete ongoing professional practice evaluations.
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10 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs’ determinations to continue privileges are based in part on results of ongoing professional practice evaluation activities.
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11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff’s decisions to recommend continuation of privileges are based on focused and ongoing professional practice evaluation results and documents its decision in the meeting minutes.
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12 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare practitioners’ departure from the healthcare system.
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13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes psychological disease and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
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14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
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15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent prior to initiating patients on long-term opioid therapy.
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16 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator delivers at least five outreach activities each month.
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17 The System Director evaluates and determines any additional reasons for noncompliance and ensures all staff receive initial and annual refresher suicide prevention training.
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18 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Austell 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.
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19 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings.
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20 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity ranges are monitored and maintained in the gastroenterology clean scope rooms.
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21 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
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22 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all staff who reprocess reusable medical equipment complete monthly continuing education.
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23 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and ensures that nursing staff refrain from scanning duplicate wristbands and follow VHA bar code medication administration processes.
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| 19-08542-11 | Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died | Hotline Healthcare Inspection | ||
1 The Veterans Crisis Line Director conducts a comprehensive review of the Caller’s contacts and staff documentation on the day of the Caller’s death, consults with Human Resources and General Counsel Offices, and takes action as warranted.
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2 The Veterans Crisis Line Director evaluates the effectiveness of current training for responders on lethal means assessment, takes action as warranted, and ensures supervisory oversight of lethal means assessments and related documentation.
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3 The Veterans Crisis Line Director provides written guidance on responders’ documentation of supervisory consultation and considers implementing independent supervisory documentation.
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4 The Veterans Crisis Line Director establishes policy and training for responders’ assessment of callers’ substance use and overdose risk, and monitors compliance.
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5 The Veterans Crisis Line Director expedites the decision whether to implement a standardized safety plan template and ensures completion of safety planning per Veterans Crisis Line standards.
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6 The Veterans Crisis Line Director evaluates the criteria for supervisory follow-up including silent monitoring criteria and internal program review outcomes and takes action, as warranted.
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7 The Veterans Crisis Line Director implements a system to identify caller contacts that warrant root cause analysis or other internal reviews and tracks the review process to completion and includes interviews of all relevant staff.
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8 The Office of Mental Health and Suicide Prevention Program Executive Director expedites efforts to develop suicide prevention strategies for weekend and holiday callers who are identified at increased risk for suicide.
Closure Date:
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| 20-00130-06 | Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center in Dublin, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are developed and documented in the Quality Executive Board
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioner profiles.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
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4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
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5 The Chief of Staff determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
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6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that nonclinical staff receive the required Operation S.A.V.E. training during new employee orientation.
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7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
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8 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:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned to and consistently attend Women Veterans Health Committee meetings.
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10 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief maintains an accurate file for all reusable medical equipment that includes the current manufacturers’ instructions for use.
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11 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturers’ instructions for use, are reviewed at least every three years, and are updated when there is a change.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that written records of weekly eyewash station testing are maintained.
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14 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and certifies that Sterile Processing Services staff complete and document liquid disinfectant solution testing to ensure the minimum effective concentration of the active ingredient is achieved.
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15 The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that annual airflow testing is conducted in the Gastroenterology Sterile Processing Services storage room.
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16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and verifies that eating, drinking, and food item storage is prohibited where the processes of decontamination, sterilization, or clean and sterile storage are performed.
Closure Date:
17 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Closure Date:
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| 20-00132-04 | Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines the reasons for noncompliance and ensures that peer reviewers consistently use at least one of the nine aspects of care for evaluations.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners with similar training and privileges complete focused and ongoing professional practice evaluations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum nuclear medicine-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
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4 The Chief of Staff determines the reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
Closure Date:
6 The Medical Center Director determines the reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
7 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that flooring in the inpatient behavioral health unit seclusion room is made of material that provides cushioning.
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8 The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.
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9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual training thereafter.
Closure Date:
10 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.
Closure Date:
11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders and is comprised of required core members who consistently attend meetings.
Closure Date:
12 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
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13 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is stored.
Closure Date:
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| 20-01326-08 | Management of the Ophthalmology Clinic and Patient Safety Reporting Concerns at the VA Central Iowa Health Care System in Des Moines | Hotline Healthcare Inspection | ||
1 The VA Central Iowa Health Care System Director ensures Ophthalmology Clinic staff are trained on how to identify, analyze, and report patient safety events and close calls.
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2 The VA Central Iowa Health Care System Director ensures that patient safety events and close calls are entered into the Joint Patient Safety Reporting system, and monitors for compliance.
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3 The VA Central Iowa Health Care System Director develops an action plan to address the culture within the Ophthalmology Clinic and monitors effectiveness.
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4 The VA Central Iowa Health Care System Director reviews the oversight and management of the Ophthalmology Clinic, makes recommendations for improvement, and monitors effectiveness.
Closure Date:
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| 19-08106-273 | Deficiencies in Care and Excessive Use of Restraints for a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
Closure Date:
2 The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
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3 The Charlie Norwood VA Medical Center Director ensures Emergency Department and Inpatient Medical Unit staff performs vital sign assessment and monitors patients who received sedating medications.
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4 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nurses accurately document medication administration.
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5 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit staff implement patient restraint management according to the Charlie Norwood VA Medical Center policy, including documentation, physician orders, and education requirements.
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6 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nursing staff communicate with providers regarding patients’ refusal of treatment.
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7 The Charlie Norwood VA Medical Center Director strengthens Inpatient Medical Unit nicotine replacement therapy processes and monitors compliance.
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8 The Charlie Norwood VA Medical Center Director strengthens processes to include the patient, family members, or surrogate in informed consent procedures and treatment decisions, as appropriate, and monitors compliance.
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9 The Charlie Norwood VA Medical Center Director evaluates the inpatient mental health consult process, and addresses timeliness and completion of decision-making capacity consult requests, and monitors compliance.
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10 The Charlie Norwood VA Medical Center Director consults with the Office of General Counsel regarding policies related to the management of patients presenting under a Form 1013 and advises policy and practices consistent with Georgia State mental health laws and takes action, as appropriate.
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11 The Charlie Norwood VA Medical Center Director ensures staff adhere to inter-facility transfer policies and procedures, including accurate communication of patients’ restraint management status, and monitors compliance.
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12 The Charlie Norwood VA Medical Center Director ensures that a consultation liaison psychiatrist is included on code gray teams at both divisions.
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13 The Charlie Norwood VA Medical Center Director evaluates inpatient mental health consult staffing and establishes a plan to ensure adequate staffing to complete consult requests as required without outpatient mental health appointment cancellations and monitors compliance.
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14 The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
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15 The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
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16 The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee reviews patient record flags and provides input into patients’ management to mitigate violence, as required by Veterans Health Administration, and monitors compliance.
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17 The Charlie Norwood VA Medical Center Director makes certain that staff receive education in code gray policy and procedures, including completion of the code gray evaluation form, and monitors compliance.
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18 The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee provides oversight of the code gray team activities, as required by Charlie Norwood VA Medical Center policy, and monitors compliance.
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| 18-04150-261 | VA’s Noncompliance with Preaward Review Requirements for Sole-Source Proposals for Healthcare Services | Review | ||
1 The OIG recommends the VHA executive director for procurement ensures contracting officers are requesting preaward reviews for all sole source healthcare resource contracts with an annual value at or above $400,000 in keeping with the May 2018 revisions to VA Directive 1663.
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2 The OIG recommends the VHA executive director for procurement require an OIG preaward review for all interim contracts that exceed the $400,000 annual threshold.
3 The OIG recommends the VHA executive director for procurement mandate an immediate postaward review for any sole source contract awarded on an interim basis as an emergency contract.
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| 19-00226-245 | Lack of Adequate Controls for Choice Payments Processed through the Plexis Claims Manager System | Audit | ||
1 The OIG recommended the VA deputy under secretary for health for the Office of Community Care Define the terms “verifiable usual and customary charges that are billed to payers other than VA” for the PC3/Choice contract claims.
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2 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure future community care programs have applicable definitions and guidance for claims without a Medicare or VA fee schedule rate to avoid reimbursements that pay at “billed charges.”
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3 The OIG recommended the VA deputy under secretary for health for the Office of Community Care create a master usual and customary rate schedule to be used for reimbursement of community care claims without a Medicare or VA fee schedule rate to control program costs.
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4 The OIG recommended the VA deputy under secretary for health for the Office of Community Care provide parties responsible for reimbursing PC3/Choice and future community care program claims with usual and customary rate price schedules and a formal written policy on the proper application of those rates.
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5 The OIG recommended the VA deputy under secretary for health for the Office of Community Care establish controls for verifiable usual and customary rate payment methodology and establish a payment review process to ensure usual and customary rates are properly applied to the PC3/Choice and future community care program payments.
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6 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure payment-rate schedules used by the Plexis Claims Manager and future payment systems to support the PC3/Choice and future community care contracts are current, accurate, and complete to prevent overpayments.
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7 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure that the Office of Community Care determines an appropriate reimbursement process for the identified pass-through errors in this report.
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8 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure the Office of Community Care establishes formal policies and procedures to identify and recover overpayments from PC3/Choice third-party administrators for improperly billed claims.
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15169