Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-03807-223 | Combined Assessment Program Summary Report – Evaluation of Compounded Sterile Product Practices in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that for employees who prepare compounded sterile products, facilities include in their competency assessment requirements gloved fingertip sampling and the required number of gloved fingertip samplings for initial competency assessment.
Closure Date:
2 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities include in the competency assessment checklists of employees who prepare compounded sterile products donning of personal protective equipment in the required order and performance of appropriate hand hygiene after personal protective equipment removal.
Closure Date:
3 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure competency assessments for employees who prepare compounded sterile products include gloved fingertip sampling, written tests, and visual observation or “hands-on” skill assessment of aseptic technique at the required risk level frequency.
Closure Date:
4 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure sterile chemotherapy-type gloves are available in areas where hazardous compounded sterile products are prepared.
Closure Date:
5 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure employees clean sterile compounding area floors daily and storage shelving monthly and document the cleaning.
Closure Date:
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| 15-04681-228 | Healthcare Inspection – Consult Management Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that providers assign the proper inpatient/outpatient setting and urgency of consults in the electronic health record.
Closure Date:
2 We recommended that the Facility Director ensure that staff take action within 7 days of a consult request or sooner if clinically indicated.
Closure Date:
3 We recommended that the Facility Director ensure that staff timely close or discontinue consults.
Closure Date:
4 We recommended that the Facility Director ensure that staff conduct a review on the quality and timeliness of the cardiology care for Patient 1 as discussed in the report, and take action if appropriate.
Closure Date:
5 We recommended that the Facility Director ensure that staff monitor and address the care needs of patients on the Homemaker/Home Health Aide services electronic wait list.
Closure Date:
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| 16-02094-219 | Healthcare Inspection—Environment of Care and Other Quality Concerns, Cincinnati VA Medical Center, Cincinnati, Ohio | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.
Closure Date:
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| 15-01325-205 | Healthcare Inspection – Community Nursing Home Program Safety Concerns, VA Northern California Healthcare System, Mather, California | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that program staff coordinate mental health appointments, including verifying the necessity, between facility providers and assigned community nursing home physicians prior to scheduling.
Closure Date:
2 We recommended that the Facility Director ensure clinical staff report suspected elder abuse within the required timeframe and document the reporting in the patient’s electronic health record.
Closure Date:
3 We recommended that the Facility Director ensure Non-VA Care Coordination staff timely deliver authorizations for consulted services to contracted community nursing home staff and that facility scheduling staff recognize when patients reside in a community nursing home and coordinate appointments with program or contracted community nursing home staff to ensure timely response to consults.
Closure Date:
4 We recommended that the Facility Director require program registered nurses and social workers consistently conduct monthly or quarterly follow-up visits and ensure timely resolution of patient care needs identified in these visits.
Closure Date:
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| 16-00571-207 | Clinical Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data twice a year and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility clinical managers ensure peer reviewers consistently document their use of at least one of the important aspects of care and that facility managers monitor compliance.
Closure Date:
3 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:
4 We recommended that the Patient Safety Manager enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
5 We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
Closure Date:
6 We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
Closure Date:
7 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
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 social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure all employees receive 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:
11 We recommended that Residential Recovery Center employees perform and document contraband inspections and rounds of public spaces and that managers monitor compliance.
Closure Date:
12 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
Closure Date:
13 We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.
Closure Date:
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| 16-00354-201 | Healthcare Inspection – Follow-Up Review of Management of Mental Health Consults and Other Access to Care Concerns, VA Maine Healthcare System, Augusta, Maine | Hotline Healthcare Inspection | ||
1 We recommended the System Director ensure Mental Health schedulers consistently make direct contact with patients prior to scheduling appointments and that compliance is monitored for a minimum of three months.
Closure Date:
2 We recommended the System Director ensure training and competencies are documented, complete, and up to date for all staff responsible for scheduling Mental Health appointments.
Closure Date:
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| 16-00564-170 | Clinical Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 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:
3 We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
Closure Date:
4 We recommended that Environment of Care Council meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
Closure Date:
5 We recommended that facility managers ensure fire extinguisher locations are clearly identified.
Closure Date:
6 We recommended that facility managers ensure information technology network room visitor logs contain all the required elements and monitor compliance.
Closure Date:
7 We recommended that employees store expired medications separately from medications available for administration and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure standard operating procedures for the bronchoscope are consistent with the manufacturer's instructions for use.
Closure Date:
10 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
11 We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
Closure Date:
12 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:
13 We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
Closure Date:
14 We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
Closure Date:
15 We recommended that providers perform history and physical examinations within 30 calendar days prior to the moderate sedation procedure and that facility managers monitor compliance.
Closure Date:
16 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:
17 We recommended that the facility correct the deficiencies identified for the Mental Health Residential Rehabilitation Treatment Program and that documentation reflects correction actions taken.
Closure Date:
18 We recommended that facility managers ensure the review of the hazardous materials inventory at the Marshalltown CBOC occurs twice within a 12-month period.
Closure Date:
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| 16-00565-154 | Clinical Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers implement the use of a visitors log during non-business hours and monitor compliance.
Closure Date:
3 We recommended that the facility perform quality control testing on all endoscopes and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility review quality assurance data for the anticoagulation management program quarterly as defined by local policy and that facility managers monitor compliance.
Closure Date:
5 We recommended that for patients transferred out of the facility, transferring providers consistently include documentation of patient or surrogate informed consent, VA Form 10-2649B, in transfer documentation and that facility managers monitor compliance.
Closure Date:
6 We recommended that providers consistently complete VA Form 10-2649A for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
Closure Date:
8 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 and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
Closure Date:
9 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior 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:
10 We recommended that Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Program employees at Lake Baldwin conduct and document daily bed checks and that program managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure all Mental Health Residential Rehabilitation Treatment Program emergency exit door alarms are functional and turned on at all times and that program managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure all closed circuit television monitoring cameras at the Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Programs have recording capability and that program managers monitor compliance.
Closure Date:
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| 17-02644-202 | Interim Summary Report - Healthcare Inspection - Patient Safety Concerns at the Washington DC VA Medical Center, Washington, DC | Hotline Healthcare Inspection | ||
1 We recommended the Under Secretary for Health take immediate action to ensure that necessary supplies and equipment are available in patient care areas at the Washington DC, VA Medical Center.
Closure Date:
2 We recommended the Under Secretary for Health take immediate action to implement an effective inventory management system throughout the Washington DC, VA Medical Center.
Closure Date:
3 We recommended the Under Secretary for Health take immediate action to ensure that current stock at the Washington DC, VA Medical Center does not include recalled equipment or supplies.
Closure Date:
4 We recommended the Under Secretary for Health take all appropriate steps to ensure that the environmental integrity of the sterile satellite storage areas complies with VA policy.
Closure Date:
5 We recommended the Under Secretary for Health take immediate action to create an inventory and establish accountability over the equipment and supplies in the off-site warehouse.
Closure Date:
6 We recommended the Under Secretary for Health take all appropriate steps to ensure that the Washington DC, VA Medical Center and Veterans Integrated Service Network arrange the orderly movement of goods and supplies from the warehouse that minimizes losses to the Government.
Closure Date:
7 We recommended the Under Secretary for Health deploy additional logistics staff with in-depth Generic Inventory Package experience to the Washington DC, VA Medical Center until reasonable assurances can be provided that existing logistics staff can maintain an effective inventory management system.
Closure Date:
8 We recommended the Under Secretary for Health expedite hiring of permanent positions at the Washington DC, VA Medical Center, to include the Associate VA Medical Center Director, the Nurse Executive, the Chief of Logistics, Assistant Chief of Logistics, and supply technicians.
Closure Date:
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| 15-00223-196 | Healthcare Inspection – Peer Review for Quality Management Concerns, Huntington VA Medical Center, Huntington, West Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that peer reviewers identify and evaluate surgical and non-surgical clinical events [redacted pursuant to 38 U.S.C. § 5705].
Closure Date:
2 We recommended that the Facility Director maintain full compliance with the Veterans Health Administration’s peer review directive when service-level committees conduct initial peer reviews and consider ensuring secondary review of all such cases [redacted pursuant to 38 U.S.C. § 5705].
Closure Date:
3 We recommended that the Facility Director ensure that the Peer Review Committee provides final Level of Care assignments in writing for all cases brought before it.
Closure Date:
4 We recommended that the Facility Director ensure that service chiefs select peer reviewers to conduct initial peer reviews and that protected peer review processes provide means for peer reviewers to withdraw when uncomfortable about conducting reviews.
Closure Date:
5 We recommended that the Facility Director ensure that initial peer reviewers possess the qualifications required of peers relative to the episodes of care under review.
Closure Date:
6 We recommended that the Facility Director review all cases [redacted pursuant to 38 U.S.C. § 5705]. and repeat the initial peer review process for those cases not conducted in compliance with the Veterans Health Administration’s peer review directive.
Closure Date:
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15039