Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-04546-374 | Healthcare Inspection – Quality of Care and Other Concerns, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Captain James A. Lovell Federal Health Care Center Director ensure that patients in the Community Living Center receive appropriate fall risk ratings and individualized fall intervention plans.
Closure Date:
2 We recommended that the Captain James A. Lovell Federal Health Care Center Director ensure compliance with Veterans Health Administration policies on Emergency Department provider coverage.
Closure Date:
3 We recommended that the Captain James A. Lovell Federal Health Care Center Director ensure compliance with Veterans Health Administration and Captain James A. Lovell Federal Health Care Center policies on hand hygiene practices.
Closure Date:
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| 17-02079-328 | Inspection of the VA Regional Office San Juan, Puerto Rico | Review | ||
1 We recommended that the San Juan VA Regional Office Director develop and implement a plan to ensure secondary reviewers accurately evaluate higher-level special monthly compensation and ancillary benefits claims.
Closure Date:
2 We recommended that the San Juan VA Regional Office Director implement a plan to ensure Veterans Service Center claims processing staff receive additional training on systems compliance and claims establishment procedures.
Closure Date:
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| 16-00552-341 | Clinical Assessment Program Review of the Michael E. DeBakey VA Medical Center, Houston, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers ensure floors and rolling equipment in patient care areas are clean and in good repair and monitor compliance.
Closure Date:
3 We recommended that the facility review quality assurance data for the anticoagulation management program monthly at Pharmacy and Therapeutics Committee meetings and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulants.
Closure Date:
5 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
6 We recommended that the laboratory director develop and implement a process to ensure employee competency for point-of-care testing with glucometers.
Closure Date:
7 We recommended that the laboratory director ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
Closure Date:
9 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
11 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
Closure Date:
12 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Closure Date:
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| 17-02150-340 | Inspection of the VA Regional Office St. Louis, Missouri | Review | ||
1 We recommended the St. Louis VA Regional Office Director implement a plan to provide refresher training on Special Monthly Compensation and monitor the effectiveness of that training.
Closure Date:
2 We recommended the St. Louis VA Regional Office Director implement a plan to ensure Special Monthly Compensation rating decisions receive a second signature review by a designated subject matter expert for processing.
Closure Date:
3 We recommended the St. Louis VA Regional Office Director implement a training plan, conducted by qualified staff, on the proper processing of rating reductions, and monitor the effectiveness of that training.
Closure Date:
4 We recommended the St. Louis VA Regional Office Director implement a plan to ensure rating reduction cases are processed at the end of the due process time period to minimize overpayments.
Closure Date:
5 We recommended the St. Louis VA Regional Office Director implement a plan to monitor the effectiveness of recent training for claims establishment.
Closure Date:
6 We recommended the St. Louis VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.
Closure Date:
7 We recommended the St. Louis VA Regional Office Director implement a training plan on how to properly process special controlled correspondence, and monitor the effectiveness of that training.
Closure Date:
8 We recommended the St. Louis VA Regional Office Director allocate resources to process special controlled correspondence to ensure timely responses.
Closure Date:
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| 17-00712-366 | Healthcare Inspection—Review of Improper Dental Infection Control Practices and Administrative Action, Tomah VA Medical Center, Tomah, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network 12 Director improve oversight of the Dental Clinic by performing unannounced inspections that include opportunities to interview staff privately regarding any concerns.
Closure Date:
2 We recommended that the Facility Director improve oversight of the Dental Clinic by conducting unannounced, detailed inspections to ensure adherence to Veterans Health Administration and facility infection control standards, patient safety guidelines, and other pertinent dental policies and procedures.
Closure Date:
3 We recommended that the Facility Director conduct training on when it is appropriate to report issues relating to the quality of healthcare or patient safety issues and the various options on where to report.
Closure Date:
4 We recommended that the Facility Director consult with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action, if any, for staff who failed to report the reuse of unsterile burs on patients.
Closure Date:
5 We recommended that the Facility Director ensure Environment of Care rounds are scheduled when all areas of the Dental Clinic are available to be inspected.
Closure Date:
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| 14-03822-359 | Healthcare Inspection – Alleged Provision of Care, Nursing Supervision, and Scheduling Issues at Community Based Outpatient Clinics at the Amarillo VA Health Care System, Amarillo, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Amarillo VA Health Care System Director ensure that community based outpatient clinics are appropriately staffed to provide care.
Closure Date:
2 We recommended that the Amarillo VA Health Care System Director ensure that managers conduct clinical reviews of the three Clovis Community Based Outpatient Clinic patients discussed in this report to determine whether a delay in follow-up adversely affected their outcomes and take action as appropriate.
Closure Date:
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| 15-03288-362 | Healthcare Inspection—Inconsistent Transfer Procedures for Urgent Care Clinic Patients with Stroke Symptoms, Manchester VA Medical Center, Manchester, New Hampshire | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Urgent Care Clinic providers consistently transfer stroke patients to an appropriate acute care facility in accordance with Veterans Health Administration and facility policies and procedures.
Closure Date:
2 We recommended that the Facility Director ensure that the Peer Review Committee follows Veterans Health Administration policy.
Closure Date:
3 We recommended that the Facility Director ensure that facility managers clinically review the records of the 13 patients not transferred to the non-VA acute care hospital, approximately 2.5 miles away, to determine whether patient harm occurred and take action as appropriate.
Closure Date:
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| 17-00970-327 | Inspection of VA Regional Office Wilmington, Delaware | Review | ||
1 We recommended the Wilmington VA Regional Office Director implement a plan to assess the effectiveness of second-signature reviews for Special Monthly Compensation and Ancillary Benefits claims.
Closure Date:
2 We recommended the Wilmington VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for higher-level Special Monthly Compensation and Ancillary Benefits.
Closure Date:
3 We recommended that the Wilmington VA Regional Office Director implement a plan to ensure management provides a consistent quality review process which addresses all elements required when establishing claims in the electronic record and monitor the effectiveness of that plan.
Closure Date:
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| 16-02526-358 | Healthcare Inspection – Physical Medicine and Rehabilitation Services Consult Process Concerns, Central Texas Veterans Health Care System, Temple, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that consult clinical reviews and appointment scheduling for patients are conducted in compliance with Veterans Health Administration directives and system policies.
Closure Date:
2 We recommended that Physical Medicine and Rehabilitation Services have sufficient staffing to arrange for timely consultations and appointments within the service.
Closure Date:
3 We recommended that the Facility staff who schedule Physical Medicine and Rehabilitation Services patient appointments receive annual scheduling competencies to ensure understanding of the correct process for compliance with Veterans Health Administration directives and staff are monitored for compliance.
Closure Date:
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| 17-01354-336 | Inspection of Denver VA Regional Office | Review | ||
1 We recommended the Denver VA Regional Director implement a plan to complete proposed rating reduction cases at the end of the due process period.
Closure Date:
2 We recommended that the Denver VA Regional Office Director implement a plan to ensure all claims processing staff receive formal training on claims establishment procedures and monitor the effectiveness of that training.
Closure Date:
3 We recommended the Denver VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.
Closure Date:
4 We recommended the Denver VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
Closure Date:
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15039