Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00576-310 | Clinical Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | 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 all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
Closure Date:
3 We recommended that facility managers ensure air conditioner and steam/heat ventilation grills in the Emergency Department are clean and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure refrigerators in patient nourishment kitchens do not contain unlabeled food items and monitor compliance.
Closure Date:
5 We recommended that the facility implement a policy for cleaning, disinfecting, and sterilizing reusable medical equipment.
Closure Date:
6 We recommended that facility managers ensure standard operating procedures for the colonoscope, esophagogastroduodenoscope, and duodenoscope are consistent with the manufacturers' instructions for use.
Closure Date:
7 We recommended that hemodialysis unit employees secure chemicals when not in use and that the hemodialysis unit manager monitors compliance.
Closure Date:
8 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
Closure Date:
9 We recommended that providers consistently complete VA form 10-2649A or use a properly templated inter-facility transfer note template for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
10 We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in VA Form 10-2649A, Inter-Facility Transfer Form, and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitor compliance.
Closure Date:
12 We recommended that sending nurses document transfer assessments/notes for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
13 We recommended that facility managers ensure that for emergent transfers, provider transfer notes include a statement of patient stability for transfer and that facility managers monitor compliance.
Closure Date:
14 We recommended that employees perform quality control on glucometers in accordance with the facility's policy/standard operating procedure and the manufacturer's recommendations and that facility managers monitor compliance.
Closure Date:
15 We recommended that providers include history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
Closure Date:
16 We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
Closure Date:
17 We recommended that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and that facility managers monitor compliance.
Closure Date:
18 We recommended that clinical employees discharge outpatients from the recovery area with orders given by a qualified provider or according to criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.
Closure Date:
19 We recommended that the facility integrate the community nursing home program into its quality improvement program.
Closure Date:
20 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
21 We recommended that facility managers ensure Disruptive Behavior Committee discussion of patients' disruptive or violent behavior and entry of a progress note into the patients' electronic health records.
Closure Date:
22 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
Closure Date:
23 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, ensure training is documented in employee training records, and monitor compliance.
Closure Date:
24 We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Closure Date:
25 We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document every 2-hour rounds of all public spaces, daily bed checks, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
Closure Date:
26 We recommended that facility managers ensure the Substance Abuse Residential Rehabilitation Treatment Program unit's non-main entry door is alarmed at all times and that program managers monitor compliance.
Closure Date:
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| 15-01119-315 | Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC | Administrative Investigation | ||
1 We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Mr. Hawkins.
Closure Date:
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| 17-01846-316 | Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care | National Healthcare Review | ||
1 We recommended that the Acting Under Secretary for Health require that all participating VA purchased care providers receive and review the evidence-based guidelines outlined in the Opioid Safety Initiative.
Closure Date:
2 We recommended that the Acting Under Secretary for Health implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history until a more permanent electronic record sharing solution can be implemented.
Closure Date:
3 We recommended that the Acting Under Secretary for Health require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording of the prescriptions in the patient’s VA electronic health record.
Closure Date:
4 We recommended that the Acting Under Secretary for Health ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with Opioid Safety Initiative guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.
Closure Date:
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| 17-00962-262 | Inspection of the Veterans Service Center Cheyenne, Wyoming | Review | ||
1 We recommended that the Denver VA Regional Office Director ensure that the Cheyenne Veterans Service Center implement a plan to ensure that all claims processing staff receive training regarding the proper procedures for inputting dates of claim for system generated reminder notifications.
Closure Date:
2 We recommended that the Denver VA Regional Office Director ensure that the Cheyenne Veterans Service Center implement a plan to perform monthly quality reviews of all employees who establish claims.
Closure Date:
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| 16-00579-293 | Clinical Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, corrective actions taken to address identified deficiencies, and tracking of corrective actions to closure.
Closure Date:
2 We recommended that the facility implement actions to address all high-risk areas and ensure Infection Control Committee minutes document those actions and the follow-up on actions implemented to address identified problems.
Closure Date:
3 We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
Closure Date:
4 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
Closure Date:
5 We recommended that the facility review quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
Closure Date:
7 We recommended that facility managers ensure that clinicians consistently obtain all required laboratory tests prior to initiating anticoagulation warfarin treatment and that clinicians obtain initial prothrombin/international normalized ratio through laboratory testing.
Closure Date:
8 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
9 We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
10 We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
Closure Date:
11 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility¿s capacity and monitor compliance.
Closure Date:
13 We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
Closure Date:
14 We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
Closure Date:
16 We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
Closure Date:
17 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
18 We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags and ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
Closure Date:
19 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:
20 We recommended that clinicians provide education and counseling to patients with positive alcohol screens and who reported drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
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| 16-00748-319 | Healthcare Inspection - Management of Mental Health Care Concerns, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Mental Health Residential Rehabilitation Treatment Program local policies are consistent with the Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Handbook and Mental Health Residential Treatment Program leaders and staff adhere to the policies.
Closure Date:
2 We recommended that the Facility Director ensure that the Mental Health Residential Rehabilitation Treatment Program managers monitor compliance as outlined by Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Handbook.
Closure Date:
3 We recommended that the Facility Director ensure that the Mental Health Residential Rehabilitation Treatment Program has adequate resources, including staff, as specified by the Mental Health Residential Rehabilitation Treatment Program Handbook to provide a safe therapeutic environment.
Closure Date:
4 We recommended that the Facility Director ensure full implementation of the Acute Mental Health Inpatient Unit visitation policy and monitor for compliance.
Closure Date:
5 We recommended that the Facility Director implement assignments of Mental Health Treatment Coordinators to mental health patients and strategies to enhance communication and coordination across mental health clinical areas.
Closure Date:
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| 16-00573-309 | Clinical Assessment Program Review of the Montana VA Health Care System, Fort Harrison, Montana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility replace missing and stained ceiling tiles in patient care areas and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers ensure standard operating procedures for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with the manufacturers’ instructions for use.
Closure Date:
3 We recommended that Sterile Processing Service employees document positive quality control testing results for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography in a manner that allows tracking of actions taken and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility provide patients with a direct telephone number for anticoagulation-related calls during normal business hours and define a process for anticoagulation calls outside normal business hours.
Closure Date:
5 We recommended that the facility designate a physician anticoagulation program champion.
Closure Date:
6 We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
8 We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
Closure Date:
9 We recommended that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility note the absence of adverse events in Operative and Invasive Procedure Committee reports and that facility managers monitor compliance.
Closure Date:
11 We recommended that clinical managers ensure clinical employees who perform or assist with moderate sedation procedures have current Talent Management System training for the provision of moderate sedation care, ensure the training is documented, and monitor compliance.
Closure Date:
12 We recommended that the facility revise the policy on ensuring correct surgery and invasive procedures to include all elements of the timeout checklist required by Veterans Health Administration Directive 1039.
Closure Date:
13 We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
Closure Date:
14 We recommended that facility managers ensure social workers conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
15 We recommended that the facility revise the workplace violence prevention policy to include required membership for the Disruptive Behavior Committee.
Closure Date:
16 We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters Patient Record Flags into the electronic health records.
Closure Date:
17 We recommended that the facility implement a process to ensure all surgical deaths are tracked and reviewed by appropriate clinical employees.
Closure Date:
18 We recommended that acute care employees accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that facility managers monitor compliance.
Closure Date:
19 We recommended that clinic employees document in patients’ electronic health records medication reconciliation that includes the newly prescribed fluoroquinolone, patient counseling/education that includes the fluoroquinolone, and evaluation of the patients’ level of understanding of the education.
Closure Date:
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| 16-02468-281 | Audit of VHA's Alleged Inappropriate Scheduling of Electromyography Consults at the Memphis VA Medical Center | Audit | ||
1 We recommended the Director of the Memphis VA Medical Center ensure Neurology Clinic staff schedule veterans referred to the Electromyography Clinic and place veterans on the Veterans¿ Choice List in accordance with Veterans Choice Program guidance when appointments are scheduled 30 days beyond the clinically indicated date.
Closure Date:
2 We recommended the Director of the Memphis VA Medical Center ensure the VA Electromyography Clinic has sufficient staffing resources to comply with VHA’s scheduling policy to act on consults within seven days.
Closure Date:
3 We recommended the Director of the Memphis VA Medical Center ensure the Business Office has sufficient staffing resources to enable timely processing of Veterans Choice Program consults.
Closure Date:
4 We recommended the Director of the Memphis VA Medical Center ensure staff review the six Veterans Choice Program consults for Electromyography services that were not scheduled for care.
Closure Date:
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| 16-00580-303 | Clinical Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky | 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 the Infection Control Committee document analysis of surveillance data related to follow-up activities for the hemodialysis unit and Sterile Processing Service areas.
Closure Date:
3 We recommended that facility managers at the Cooper Division implement the use of a visitors log during non-business hours and monitor compliance.
Closure Date:
4 We recommended that facility managers at the Cooper Division ensure ceiling ventilation grills in patient care areas are clean and monitor compliance.
Closure Date:
5 We recommended that Sterile Processing Service managers ensure quality control testing is performed on endoscopes that exceed a 12-day hang time and monitor compliance.
Closure Date:
6 We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training and competencies for the types of reusable medical equipment they reprocess.
Closure Date:
7 We recommended that facility managers ensure wall and ceiling holes and damage are repaired.
Closure Date:
8 We recommended that facility managers ensure employees entering Sterile Processing Service areas wear the required personal protective equipment and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure current standard operating procedures for reusable medical equipment are located in the area where reprocessing occurs.
Closure Date:
10 We recommended that facility managers ensure the distance of items stored below a sprinkler deflector complies with Joint Commission standards and monitor compliance.
Closure Date:
11 We recommended that facility managers ensure all hemodialysis unit employees receive annual bloodborne pathogens training and monitor compliance.
Closure Date:
12 We recommended that the facility revise the anticoagulation management policy to include required baseline laboratory tests.
Closure Date:
13 We recommended that the facility review quality assurance data for the anticoagulation management program biannually and that facility managers monitor compliance.
Closure Date:
14 We recommended that facility managers include nutrient interactions and drug to drug interactions associated with anticoagulation therapy in competency assessments for employees actively involved in the anticoagulant program and monitor compliance.
Closure Date:
15 We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
Closure Date:
16 We recommended that clinical employees discharge outpatients from the recovery area according to provider orders or criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.
Closure Date:
17 We recommended that clinical managers ensure that clinical employees who perform or assist with moderate sedation have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
Closure Date:
18 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required disciplines.
Closure Date:
19 We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
Closure Date:
20 We recommended that facility managers ensure that registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
21 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal flag placement and monitor compliance.
Closure Date:
22 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, ensure the training is documented in employee training records, and monitor compliance.
Closure Date:
23 We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program monthly self-inspections include assessment of privacy and that facility managers monitor compliance.
Closure Date:
24 We recommended that facility managers ensure locked mental health unit panic alarm testing includes VA Police response time and monitor compliance.
Closure Date:
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| 15-04641-304 | Healthcare Inspection – Quality of Care and Other Concerns Robert J. Dole VA Medical Center, Wichita, Kansas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement applicable recommendations from previous event-related reviews and monitor compliance.
Closure Date:
2 We recommended that the Facility Director ensure that processes are strengthened for the Hospice and Palliative Care Program and that appropriate designated staff are assigned to the Palliative Care Consult Team to adhere to Veterans Health Administration and facility policy.
Closure Date:
3 We recommended that the Facility Director assess the need to define the required timeframe for attending physicians to return to the facility if needed for patient emergencies.
Closure Date:
4 We recommended that the Facility Director ensure compliance with facility policy for clinicians designated to perform emergency airway management.
Closure Date:
5 We recommended that the Facility Director ensure compliance with Veterans Health Administration policies on Emergency Department coverage.
Closure Date:
6 We recommended that the Facility Director ensure the continued practice of physician only coverage for the role of nocturnist.
Closure Date:
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14957