Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-03700-283 | Review of VA's Guidance on Protecting Religious Beliefs | Audit | ||
1 We recommended the Interim Under Secretary for Memorial Affairs rescind and replace Chapters 6 and 7 from Manual 40-2, National Cemeteries, Administration, Operation, and Maintenance.
Closure Date:
2 We recommended the Interim Under Secretary for Memorial Affairs recertify or rescind Directive 3170/1, Ceremonies and Special Events at VA National Cemeteries.
Closure Date:
3 We recommended the Interim Under Secretary for Memorial Affairs incorporate National Cemetery Administration’s three interim guidance documents into directives or handbooks.
Closure Date:
4 We recommended the Interim Under Secretary for Memorial Affairs develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
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5 We recommended the Under Secretary for Health recertify or rescind Veterans Health Administration’s three religious belief guidance documents that need to be updated.
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6 We recommended the Under Secretary for Health develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
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7 We recommended the Under Secretary for Health provide staff a means to request senior official assistance, when necessary, to obtain timely agency-level concurrences.
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| 16-00118-321 | Combined Assessment Program Review of the Amarillo VA Health Care System, Amarillo, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility set triggers for when a Focused Professional Practice Evaluation for cause would be indicated.
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2 We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
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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.
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4 We recommended that designated employees follow the facility policy for identification of individuals entering the facility after normal business hours and that facility managers monitor compliance.
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5 We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
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6 We recommended that facility managers ensure employees perform and consistently document monthly cleaning of walls and light fixtures in all compounding areas and monitor compliance.
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7 We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
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8 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
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9 We recommended that clinicians include contact numbers of family or friends for support and an assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
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10 We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
Closure Date:
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| 16-00027-318 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Connecticut Healthcare System, West Haven, Connecticut | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensures that fire drills and fire drill critiques are conducted at least every 12 months at the Winsted VA Clinic.
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2 We recommended that the Winsted VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
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3 We recommended that providers sign Home Telehealth assessments and treatment plans.
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4 We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
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5 We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
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| 16-00029-322 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Jesse Brown VA Medical Center, Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility revise the local policy to include specific procedures for the identification of individuals entering the CBOCs.
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2 We recommended that the facility ensure a safe work
environment with adequate security coverage and incident responses at the Auburn Gresham VA Clinic.
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3 We recommend that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
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5 We recommended that the facility update its template to ensure providers’ plans of care and disposition are accurately documented for patients with positive PTSD screens.
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| 16-00121-320 | Combined Assessment Program Review of the Jesse Brown VA Medical Center, Chicago, Illinois | 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.
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2 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
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4 We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
Closure Date:
5 We recommended that employees wear personal protective equipment and gloves when compounding sterile products in the operating room satellite pharmacy and that facility managers monitor compliance.
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6 We recommended that sending nurses document transfer assessments and receiving nurses document transfer notes and that facility managers monitor compliance.
Closure Date:
7 We recommended that attending physicians co-sign resident physicians’ discharge notes/instructions and that facility managers monitor compliance.
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8 We recommended that the facility review and revise its advance directives policy to ensure it is consistent with Veterans Health Administration policy.
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9 We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
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10 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
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11 We recommended that employees consistently use appropriate note titles to document screening and that facility managers monitor compliance.
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12 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
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13 We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
Closure Date:
14 We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that plans include contact numbers of family or friends for support and assessment of available lethal means and how to keep the environment safe and that facility managers monitor compliance.
Closure Date:
15 We recommended that clinicians perform and document patient assessments following blood product transfusions and that facility managers monitor compliance.
Closure Date:
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| 14-03183-317 | Healthcare Inspection - Alleged Patient Safety Concerns, Miami VA Healthcare System, Miami, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that Community Living Center patients, families, and staff know the circumstances and guidelines under which they should initiate Integrated Ethics consults, have access to the Ethics Consultation Service, and know how to request an ethics consultation.
2 We recommended that the System Director ensure that Community Living Center staff receive training regarding suicide risk factors and the importance of documenting and communicating identified suicide risk factors during Interdisciplinary Team meetings.
3 We recommended that the System Director ensure that system clinical leadership reviews current practices of the ordering and administration of sleeping medications in the Community Living Center to determine if those practices optimize patient safety.
4 We recommended that the System Director ensure that reviews of incidents involving patient safety are comprehensive and accurately reflect and document all components as outlined in the VHA National Patient Safety Improvement Handbook guidelines.
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| 14-04435-265 | Healthcare Inspection – Mental Health Service Concerns at the Knoxville VA Outpatient Clinic, James H. Quillen VA Medical Center, Mountain Home, Tennessee | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director improve processes for communicating with community-based consumer-run groups that provide mental health services to veterans enrolled at the Knoxville VA Outpatient Clinic.
Closure Date:
2 We recommended that the Facility Director ensure that the Clinic’s Veterans Justice Outreach Specialist provides comprehensive services including outreach for veterans in the Knox and surrounding counties in accordance with Veterans Health Administration policy.
Closure Date:
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| 16-01489-311 | Combined Assessment Program Summary Report – Evaluation of Coordination of Inpatient Consults in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinicians consistently include ‘inpatient’ in the inpatient consult title and that facility managers monitor compliance.
Closure Date:
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| 16-00111-310 | Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | 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 the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
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3 We recommended that Environment of Care Board meeting minutes include corrective actions taken to address rounds deficiencies.
Closure Date:
4 We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
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5 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
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6 We recommended that facility managers ensure medical waste/biohazard containers are properly covered and monitor compliance.
Closure Date:
7 We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
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8 We recommended that employees date multi-dose medication vials when opened and that facility managers monitor compliance.
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9 We recommended that facility managers ensure all sharps containers are closed and monitor compliance.
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10 We recommended that dental clinic managers ensure all dental clinic employees complete hazard communication training on chemical classification, labeling, and safety data sheets and monitor compliance.
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11 We recommended that facility managers ensure consistent monitoring of operating room temperature, humidity, and positive pressure.
Closure Date:
12 We recommended that facility managers ensure all operating room exits are unobstructed and monitor compliance.
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13 We recommended that the facility revise the competency assessment policy for employees who prepare compounded sterile products to include the required intervals for gloved fingertip sampling.
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14 We recommended that the facility revise the compounded sterile products safety/competency assessment checklist to include donning of personal protective equipment in the required order and the performance of appropriate hand hygiene after personal protective equipment removal.
Closure Date:
15 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
16 We recommended that the facility revise its temporary bed locations policy to include priority placement for inpatient beds given to patients in temporary bed locations.
Closure Date:
17 We recommended that physicians document transfer notes and that facility managers monitor compliance.
Closure Date:
18 We recommended that receiving physicians document transfers and that facility managers monitor compliance.
Closure Date:
19 We recommended that a medical physicist complete and document inspections of computed tomography scanners following repair or modifications affecting dose or image quality and that facility managers monitor compliance.
Closure Date:
20 We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
Closure Date:
21 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
22 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
23 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
24 We recommended that clinicians include assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
25 We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Closure Date:
26 We recommended that facility managers ensure the Domiciliary Care for Homeless Veterans Program is clean and monitor compliance.
Closure Date:
27 We recommended that the facility repair or replace identified items in the Domiciliary Care for Homeless Veterans Program.
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28 We recommended that the facility correct the deficiencies identified in the Domiciliary Care for Homeless Veterans Program and that documentation reflects correction.
Closure Date:
29 We recommended that facility managers ensure the Domiciliary Care for Homeless Veterans Program has closed circuit television monitors with recording capability in public areas and does not have monitors installed in treatment areas.
Closure Date:
30 We recommended that facility managers ensure exit signs on Domiciliary Care for Homeless Veterans Program resident floors are visible.
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| 15-02747-314 | Administrative Investigation - Alleged Prohibited Personnel Practice, Board of Veterans Appeals, Washington, DC | Administrative Investigation | ||
1 We recommend that the VA Deputy Secretary confer with the Offices of General Counsel and Human Resources Management to develop VA policy related to the staffing and recruitment of VLJs, incorporate it into proper guidance and a requirement to sign a confidentiality agreement, provide applicability of the Privacy Act, a clear definition of what is confidential, and ensure that policy is implemented.
Closure Date:
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15039