Recommendations
2037
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-02690-167 | Deficiencies in Crisis Management of a Client, Crisis Reporting, and Documentation Practices at the Everett Vet Center in Washington | Hotline Healthcare Inspection | ||
1 The District 5 Director conducts a full review of care provided to the client by the Everett Vet Center Director and counselor, consults with Human Resources and General Counsel Offices, and takes action as needed.
2 The District 5 Director ensures vet center leaders and staff are knowledgeable about applicable state laws pertaining to duty to warn.
3 The District 5 Director makes certain that the Everett Vet Center Director and staff adhere to requirements for consultation with support facility external consultants and suicide prevention coordinators when indicated, and monitors compliance.
4 The Chief Officer, Readjustment Counseling Service provides written guidance to clarify crisis reporting criteria and monitoring responsibilities.
5 The Chief Officer, Readjustment Counseling Service establishes written policy that clarifies clinical record documentation requirements regarding entry dates; non-visit progress note completion time frames; and progress note deletion and addition, and monitors compliance.
6 The Chief Officer, Readjustment Counseling Service establishes written guidance regarding time requirements for the completion of risk assessment documentation in clients’ clinical records.
7 The District 5 Director ensures readjustment counselors’ compliance with updating and reviewing safety plans as required by Readjustment Counseling Service policy.
8 The Chief Officer, Readjustment Counseling Service ensures that vet center directors are issued the correct position description and are performing duties within the identified scope of work.
9 The District 5 Director conducts a review of the care provided to complex clients by the Everett Vet Center Director since March 2021 and addresses identified clinical needs.
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| 24-02031-171 | Care in the Community Deficiencies and Ineffective VISN Oversight at the VA Maryland Health Care System in Baltimore | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health assesses the feasibility of the 7-day appointment scheduling requirement for Care in the Community consults and considers stratifying the time frame requirement according to risk.
2 The VA Maryland Health Care System Director develops and implements an education plan to address incomplete Care in the Community consult submissions and monitors efficacy of the plan.
3 The VA Maryland Health Care System Director implements Care in the Community consult management process improvements, focusing on consult completion.
4 The Veterans Integrated Service Network Director assists system leaders with completing corrective actions to improve Care in the Community performance.
5 The VA Maryland Health Care System Director ensures system Care in the Community staff create and use care coordination plan notes for documenting all care coordination activities for consults with an assigned level of care other than basic and monitors for compliance.
6 The VA Maryland Health Care System Director ensures full implementation of Veterans Health Administration’s enhanced Referral Coordination Initiative as required and monitors for compliance.
7 The VA Maryland Health Care System Director ensures Care in the Community Patient Advocate Tracking System data is analyzed for use in service-level quality and process improvement and monitors for compliance.
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| 24-02430-152 | Delays in Pension Automation Updates Led to Some Burial Transportation Benefits Being Incorrectly Processed | Review | ||
1 Update the relevant sections on transportation expenses in the Veterans Benefits Administration’s Adjudication Procedures Manual to align with each other.
Closure Date:
2 Ensure automation is consistent with the policy for processing the transportation benefit.
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| 24-00615-163 | Healthcare Facility Inspection of the Sheridan VA Health Care System in Wyoming | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders implement tools to help sensory-impaired veterans navigate the facility.
2 The OIG recommends facility leaders ensure the facility has a policy for test result communication that includes methods to monitor the effectiveness of the patient notification process.
3 The OIG recommends facility leaders ensure staff develop workflows for the communication of test results for each service.
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| 24-00613-162 | Healthcare Facility Inspection of the VA Boston Healthcare System in Massachusetts | Healthcare Facility Inspection | ||
1 The OIG recommends the Director ensures staff have processes to prevent repeat environment of care findings.
2 The OIG recommends the Veterans Integrated Service Network 1 Director monitors for similar or repeated environment of care findings and ensures facility staff sustain improvements.
3 The OIG recommends the Veterans Integrated Service Network 1 Director ensures facility leaders identify environment of care trends and establish performance improvement plans with outcome measures to address them.
4 The OIG recommends the Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present.
5 The OIG recommends the Director ensures staff keep patient care areas clean and safe.
6 The OIG recommends the Director ensures only authorized staff have access to medication storage areas.
7 The OIG recommends the Director ensures staff conduct an inventory of all the facility’s medication storage areas, and the Chief of Pharmacy approves them.
8 The OIG recommends the Chief of Pharmacy ensures pharmacy staff inspect each approved medication storage area monthly.
9 The OIG recommends the Director ensures staff monitor temperature and humidity in medication storage areas and track possible deviations, even those that may occur when the areas are closed.
10 The OIG recommends the Director ensures the Brockton VA Medical Center’s Urgent Care Center operates according to VHA Directive 1101.13 and obtains an appropriate waiver from the VHA National Program Office of Emergency Medicine as applicable.
Closure Date:
11 The OIG recommends facility leaders review the local policy to ensure it complies with VHA directives specific to which staff receive notification of critical test results.
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| 24-00610-164 | Healthcare Facility Inspection of the VA Connecticut Healthcare System in West Haven | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders develop and implement a plan to address veterans’ unanswered phone calls.
2 The OIG recommends the Associate Director ensures staff identify environment of care trends and establish performance improvement plans with outcome measures to address them.
3 The OIG recommends the Associate Director ensures the manufacturer satisfies contractual requirements to perform preventive maintenance for beds and stretchers and documents the service.
4 The OIG recommends the Veterans Integrated Service Network Director works with facility and primary care leaders to address the network call center’s effect on primary care team efficiency and workload and reduce the risk of adverse patient safety events.
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| 24-02806-157 | Deficiencies in Credentialing, Privileging, and Evaluations for Surgeons at the St. Cloud VA Medical Center in Minnesota | Hotline Healthcare Inspection | ||
1 The St. Cloud VA Medical Center Director completes a comprehensive review of surgical service credentialing and privileging processes, ensures facility policy and practice in alignment with Veterans Health Administration policy, and as necessary, consults with Veterans Integrated Service Network leaders, and monitors for compliance.
2 The St. Cloud VA Medical Center Director reviews the processes specific to ongoing professional practice evaluations, ensures alignment with Veterans Health Administration policy, including surgical service chief consideration of the use of specialty-specific metrics, including surgical procedures performed in the operating room, and monitors compliance.
3 The St. Cloud VA Medical Center Director completes a review of Medical Staff Executive Council meeting minutes, specific to focused and ongoing professional practice evaluations for the surgical service chief, identifies deficiencies, and takes action as warranted to ensure completion according to Veterans Health Administration requirements.
4 The St. Cloud VA Medical Center Director, in conjunction with Veterans Integrated Service Network leaders, ensures that Veterans Health Administration state licensing board reporting processes are followed for surgeon A consistent with Veterans Health Administration Directive 1100.18.
Closure Date:
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| 24-02142-105 | VA Needs to Prioritize Accessibility for Individuals with Disabilities When Procuring Information Technology Systems | Audit | ||
1 Ensure staff involved with acquiring information and communication technology are adequately trained on federal and VA requirements for Section 508 standards.
2 Update VA Handbook 6221 to clearly identify roles and responsibilities related to ensuring Section 508 compliance during procurement.
3 Establish a way to ensure compliance documentation and market research on any information and communication technology being procured are submitted to the VA Office of 508 Compliance for approval so that the office can determine whether the technology is the most compliant under Section 508.
4 Collaborate with the VA Office of 508 Compliance to develop policies and procedures to ensure VA’s information and communication technology procurements comply with Section 508 requirements.
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| 24-01862-151 | Mental Health Inspection of the VA Philadelphia Healthcare System in Pennsylvania | Mental Health Inspection Program | ||
1 The Facility Director establishes a mental health executive council that operates in accordance with Veterans Health Administration requirements.
2 The Facility Director ensures development and implementation of a multi-year recovery transformation plan.
3 The Associate Chief of Staff for Behavioral Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health units.
4 The Facility Director ensures inpatient mental health units are in good repair and the environment reflects recovery-oriented principles.
5 The Facility Director ensures veterans’ privacy in restraint rooms on the inpatient mental health units.
6 The Associate Chief of Staff for Behavioral Health develops written guidance to ensure staff and veterans’ safety during outdoor breaks.
7 The Facility Director formalizes processes to monitor and track compliance with state involuntary commitment laws.
8 The Chief of Staff ensures the completion of comprehensive inpatient mental health treatment plans and monitors for compliance.
9 The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.
10 The Chief of Staff ensures mental health treatment coordinators are included in care coordination.
11 The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.
12 The Chief of Staff ensures discharge instructions for veterans include the purpose for each listed medication in easy-to-understand language.
13 The Chief of Staff ensures discharge instructions for veterans include an explanation when both trade and generic names are used for the same medication.
14 The Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.
15 The Chief of Staff ensures safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.
16 The Facility Director ensures staff comply with timely completion of VA S.A.V.E. training requirements and monitors for compliance.
17 The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording meeting minutes and including all required members, and monitors for compliance.
18 The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool and monitors for compliance.
19 The Facility Director ensures staff address identified Mental Health Environment of Care Checklist deficiencies in accordance with Veterans Health Administration guidelines and monitors for compliance.
20 The Facility Director ensures Interdisciplinary Safety Inspection Team members comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
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| 24-01861-144 | Mental Health Inspection of the VA Salem Healthcare System in Virginia | Mental Health Inspection Program | ||
1 The Facility Director ensures the mental health executive council operates in accordance with VHA requirements.
2 The Chief of Mental Health identifies barriers and implements processes to provide a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit and monitors for compliance.
3 The Facility Director develops and implements processes to monitor and track compliance with involuntary commitment requirements.
4 The Chief of Staff ensures timely documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.
5 The Chief of Staff ensures discharge instructions for veterans are written in easy-to-understand language and include the purpose for each medication.
6 The Chief of Staff directs staff to complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.
7 The Chief of Staff directs staff to complete or review safety plans with veterans prior to discharge and monitors for compliance.
8 The Chief of Staff directs staff to address ways to make the veteran’s environment safer from potentially lethal means in safety plans and monitors for compliance.
9 The Facility Director directs staff to comply with Lethal Means Safety training and monitors for compliance.
10 The Facility Director directs staff to comply with Skills Training for Evaluation and Management of Suicide training and monitors for compliance.
11 The Facility Director directs staff to comply with VA S.A.V.E. training and monitors for compliance.
12 The Facility Director ensures Interdisciplinary Safety Inspection Team requirements are met and monitors for compliance.
13 The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards to all sections on the inpatient mental health unit and monitors for compliance.
14 The Facility Director uses VHA guidelines to develop a facility-specific policy for the use of restraint chairs.
15 The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
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