Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01157-31 | Comprehensive Healthcare Inspection Program Review of the Iowa City VA Health Care System, Iowa | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs complete all required elements, including specialty-specific criteria, for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
2 The Facility Director ensures that controlled substances program staff complete reconciliation of controlled substances returns to pharmacy stock during controlled substance inspections and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board or council and monitors compliance.
Closure Date:
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| 18-01159-38 | Comprehensive Healthcare Inspection Program Review of the West Palm Beach VA Medical Center, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
Closure Date:
3 The Director ensures implementation of root cause analysis actions and feedback of results to the reporting individuals or departments and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that service chiefs complete required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
Closure Date:
5 The Chief of Staff ensures the service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
6 The Associate Director ensures all staff are educated on how to access safety data sheet information and monitors compliance.
Closure Date:
7 The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
8 The Associate Director ensures the Port Saint Lucie Community Based Outpatient Clinic panic alarms are functional and regularly tested and monitors compliance.
Closure Date:
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| 18-01161-28 | Comprehensive Healthcare Inspection Program Review of the Salem VA Medical Center, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Facility managers develop and implement a comprehensive Facility policy on the use and care of central lines and monitor compliance.
Closure Date:
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| 18-01154-27 | Comprehensive Healthcare Inspection Program Review of the VA Pittsburgh Healthcare System, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that the Medical Executive Board uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs complete all required elements, including minimum required specialty criteria for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
3 The Deputy Director ensures that a safe and clean environment is maintained throughout the Facility and Westmoreland County Community Based Outpatient Clinic and monitors compliance.
Closure Date:
4 The Deputy Director ensures the flooring in the mental health seclusion rooms provides cushioning.
Closure Date:
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| 17-01007-01 | Inadequate Governance of the VA Police Program at Medical Facilities | Audit | ||
1 Clarify program responsibilities between the Veterans Health Administration and theOffice of Operations, Security, and Preparedness, and evaluate the need for a centralizedmanagement entity for the security and law enforcement program across all medicalfacilities.
2 Ensure police staffing models are implemented for determining facility-appropriate levelsfor officers at medical facilities.
Closure Date:
3 Make certain medical facilities use strategies to address police staffing challenges such ashaving documented recruitment plans for police officer positions that include adetermination of the need for special salary rates and incentives.
Closure Date:
4 Assess the staffing levels for the Office of Security and Law Enforcement policeinspection program, and authorize and provide sufficient resources to conduct timelyinspections of police units at medical facilities to help identify program complianceissues.
Closure Date:
5 Ensure procedures are developed for appropriately handling VA police investigations of medical facility leaders.
Closure Date:
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| 17-02163-23 | Provider Assignment and Dermatology Consult Scheduling Delays at the Joint Ambulatory Care Center, Pensacola, Florida | Hotline Healthcare Inspection | ||
1 The Gulf Coast Veterans Health Care System Director ensures that patients are assigned primary care providers, as required by Veterans Health Administration policy, and that the assignments are monitored for compliance.
Closure Date:
2 The Gulf Coast Veterans Health System Director ensures that patients with Joint Ambulatory Care Center dermatology consults are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult timeframe, and that the scheduling process is monitored for compliance.
Closure Date:
3 The Gulf Coast Veterans Health Care System Director ensures that system managers review dermatology and non-VA care scheduling staffing levels, and develop an action plan to address recommendations, if any, from the staffing level reviews.
Closure Date:
4 The Gulf Coast Veterans Health System Director takes appropriate action as related to Patient B’s physicians’ improper electronic health record documentation as discussed in this report.
Closure Date:
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| 18-01142-25 | Comprehensive Healthcare Inspection Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that service chiefs communicate to the Peer Review Committee the completion of individual improvement actions and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that all Focused Professional Practice Evaluations include clearly delineated timeframes and monitor compliance.
Closure Date:
3 The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
4 The Associate Director ensures that staff store clean and dirty equipment separately and monitors compliance.
Closure Date:
5 The Associate Director ensures the mental health unit seclusion room toilet is shatterproof.
Closure Date:
6 The Associate Director ensures that environment of care rounds are conducted as required at the McComb Community Based Outpatient Clinic and monitors compliance.
Closure Date:
7 The Associate Director ensures that staff at the McComb Community Based Outpatient Clinic remove all expired, damaged, and/or contaminated medications and monitors compliance.
Closure Date:
8 The Associate Director ensures the McComb Community Based Outpatient Clinic managers maintain a safe and clean environment and monitors compliance.
Closure Date:
9 The Associate Director ensures that shelving is clean and bottom storage shelves are solid at the McComb Community Based Outpatient Clinic and monitors compliance.
Closure Date:
10 The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive posttraumatic stress disorder screens and monitors compliance.
Closure Date:
11 The Chief of Staff ensures that acceptable providers offer and refer patients with positive posttraumatic stress disorder screens for further diagnostic evaluations and monitors compliance.
Closure Date:
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| 18-01144-24 | Comprehensive Healthcare Inspection Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from social work and the Chief Business Office revenue utilization review and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Ongoing Professional Practice Evaluations utilize assessments by providers with similar training and privileges and monitors compliance.
Closure Date:
3 The Associate Director ensures managers clearly mark and securely store medical biohazardous waste and monitors compliance.
Closure Date:
4 The Associate Director ensures the Police and Security Operations document response time to panic alarm testing at the locked mental health unit and monitors compliance.
Closure Date:
5 The Associate Director ensures that the Emergency Management Plan is reviewed annually and monitors compliance.
Closure Date:
6 The Facility Director ensures that the Quality Council maintains oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
Closure Date:
7 The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Closure Date:
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| 18-01145-26 | Comprehensive Healthcare Inspection Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
2 The Associate Director ensures the VA Police regularly test panic alarms at the Northwest Las Vegas VA Clinic and monitors compliance.
Closure Date:
3 The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing in the locked mental health unit and monitors compliance.
Closure Date:
4 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed and monitors compliance.
Closure Date:
5 The Facility Director ensures controlled substance monthly inspection dates are randomly selected to avoid distinguishable patterns and monitors compliance.
Closure Date:
6 The Facility Director ensures that controlled substances inspectors perform reconciliation of controlled substance refills to automated dispensing cabinets in patient care areas and returns to pharmacy stock and monitors compliance.
Closure Date:
7 The Facility Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and monitors compliance.
Closure Date:
8 The Facility Director ensures that Geriatrics and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
Closure Date:
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| 16-00862-179 | VA’s Oversight of State Approving Agency Program Monitoring for Post-9/11 GI Bill Students | Audit | ||
1 The Under Secretary for Benefits negotiates an amendment to State Approving Agency contracts to clarify requirements for program approvals and require, subject to the availability of resources, quarterly samples and reviews and evaluations of supporting documentation for State Approving Agency approvals to ensure approved programs meet Title 38 of the United States Code requirements.
Closure Date:
2 The Under Secretary for Benefits negotiates amendments to State Approving Agency contracts that, subject to available resources, require the State Approving Agencies to periodically reapprove programs and evaluate program changes and other operational changes, such as advertisement practices, that may affect a program’s continued eligibility and compliance with Title 38 of the United States Code.
Closure Date:
3 The Under Secretary for Benefits refers schools identified during the audit with potentially erroneous, deceptive, or misleading advertising practices to the Federal Trade Commission for it to decide whether any further reviews or actions are needed.
Closure Date:
4 The Under Secretary for Benefits revises and strengthens compliance surveys to improve the assessment of program eligibility and compliance survey quality reviews to include the review of supporting documentation and an independent assessment of the quality of the completed compliance surveys.
Closure Date:
5 The Under Secretary for Benefits negotiates an amendment to the State Approving Agency contracts to establish quality assurance metrics and ensure the Veterans Benefits Administration collects and uses quality assurance data from its reviews of the State Approving Agencies’ approvals, monitoring, and compliance surveys in its annual evaluations of the State Approving Agencies.
Closure Date:
6 The Under Secretary for Benefits assesses whether funding for State Approving Agencies is sufficient to ensure the adequate review, approval, and monitoring of programs, in conjunction with the establishment of a contract to update the State Approving Agency funding allocation model.
Closure Date:
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15169