Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-02413-55 | Review of Alleged Wasted Funds in VHA's Southern Arizona VA Health Care System | Audit | ||
1 We recommended the Veterans Integrated Service Network 18 Director ensure the Southern Arizona VA Health Care System develop and implement a policy requiring coordination and review of leased equipment requests with the Health Care System's support services during the acquisition process.
Closure Date:
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| 15-05024-97 | Inspection of the VA Regional Office in Manila, Philippines | Review | ||
1 We recommended the Manila VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
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| 14-03540-123 | Healthcare Inspection – Veterans Crisis Line Caller Response and Quality Assurance Concerns, Canandaigua, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Office of Mental Health Operations Executive Director ensure that issues regarding response hold times when callers are routed to backup crisis centers are addressed and that data is collected, analyzed, tracked, and trended on an ongoing basis to identify system issues.
Closure Date:
2 We recommended that the Office of Mental Health Operations Executive Director ensure that orientation and ongoing training for all Veterans Crisis Line staff is completed and documented.
Closure Date:
3 We recommended that the Office of Mental Health Operations Executive Director ensure that silent monitoring frequency meets the Veterans Crisis Line and American Association of Suicidology requirements and that compliance is monitored.
Closure Date:
4 We recommended that the Office of Mental Health Operations Executive Director establish a formal quality assurance process, as required by the Veterans Health Administration, to identify system issues by collecting, analyzing, tracking, and trending data from the Veterans Crisis Line routing system and backup centers and that subsequent actions are implemented and tracked to resolution.
Closure Date:
5 We recommended that the Office of Mental Health Operations Executive Director consider the development of a Veterans Health Administration directive or handbook for the Veterans Crisis Line.
Closure Date:
6 We recommended that the Office of Mental Health Operations Executive Director ensure that contractual arrangements concerning the Veterans Crisis Line include specific language regarding training compliance, supervision, comprehensiveness of information provided in contact and disposition emails, and quality assurance tasks.
Closure Date:
7 We recommended that the Office of Mental Health Operations Executive Director consider the development of algorithms or progressive situation-specific stepwise processes to provide guidance in the rescue process.
Closure Date:
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| 15-05162-93 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central California VA Health Care System, Fresno, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-05023-112 | Inspection of the VA Regional Office Oakland, California | Review | ||
1 We recommended the Oakland VA Regional Office Director conduct a review of the 58 temporary 100 percent disability evaluations remaining from the inspection universe of 88, and take appropriate action.
Closure Date:
2 We recommended the Oakland VA Regional Office Director implement a plan to ensure all claims processing staff comply with the Veterans Benefits Administration’s second-signature policy for higher levels of special monthly compensation claims.
Closure Date:
3 We recommended that the Acting Under Secretary for Benefits ensure that approved higher levels of special monthly compensation training materials are updated and accurate
Closure Date:
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| 15-05161-98 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Butler Healthcare, Butler, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Cranberry Township VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
Closure Date:
2 We recommended that managers ensure that staff at the Cranberry Township VA Clinic participate in emergency management training and exercises.
Closure Date:
3 We recommended that managers ensure that Cranberry Township VA Clinic employees receive the required hazardous communications training.
Closure Date:
4 We recommended that managers at the Cranberry Township VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
5 We recommended that clinicians complete Home Telehealth enrollment consults.
Closure Date:
6 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-04707-111 | Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility manager’s 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.
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 Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, include corrective actions to address those deficiencies, and track corrective actions to closure.
Closure Date:
5 We recommended that Hospital Epidemiology Committee meeting minutes consistently reflect discussion of identified high-risk areas and implementation of actions to address those areas and document follow-up on actions implemented to address identified problems.
Closure Date:
6 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.
Closure Date:
7 We recommended that the facility revise operating room emergency fire policy and procedures to include alarm activation, evacuation, and equipment shutdown with responsibility for turning off room or zone oxygen.
Closure Date:
8 We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes visual observation/“hands-on” skill assessment of aseptic technique and gloved fingertip sampling.
Closure Date:
9 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:
10 We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
Closure Date:
11 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
12 We recommended that special care unit sending nurses document transfer assessments and that facility managers monitor compliance.
Closure Date:
13 We recommended physicians consistently document discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
Closure Date:
14 We recommended that facility managers review the organizational alignment for the Radiation Safety Officer position to ensure compliance with Veterans Health Administration policy.
Closure Date:
15 We recommended that facility managers develop and implement a comprehensive computed tomography policy that includes a quality control program and procedures to follow when revising computed tomography protocols.
Closure Date:
16 We recommended that computed tomography technologists perform and document quality control checks, that a supervisory employee conducts periodic review to verify the checks were done, and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
Closure Date:
18 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
Closure Date:
19 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:
20 We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
21 We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
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| 15-04697-105 | Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
Closure Date:
2 We recommended that Physician Utilization Management Advisors document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility consistently take actions when data analyses indicate problems or opportunities for improvement and evaluate them for effectiveness in committee reviews, utilization management, and root cause analyses and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility conduct an annual infection prevention risk assessment.
Closure Date:
5 We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
Closure Date:
6 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
7 We recommended that the facility revise its policy for temporary bed locations to include priority placement for inpatient beds given to patients in temporary bed locations, upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
Closure Date:
8 We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
Closure Date:
9 We recommended that clinicians consistently place flags in the electronic health records of patients identified as high risk for suicide and that facility managers monitor compliance.
Closure Date:
10 We recommended that clinicians not place flags in the electronic health records of patients identified as moderate or low risk for suicide and that facility managers monitor compliance.
Closure Date:
11 We recommended that clinicians include the identification of 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:
12 We recommended that facility managers ensure electronic health record quality reviews include a representative sample of charts from each service or program.
Closure Date:
13 We recommended that facility managers ensure all non-hospice and palliative care clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
14 We recommended that facility managers establish a process to track and document hospice and palliative care consults that are not acted upon within 7 days of the request.
Closure Date:
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| 15-04708-115 | Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania | 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 clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Patient Safety Manager submit an annual patient safety report to facility leaders at the completion of each fiscal year.
Closure Date:
5 We recommended that the facility revise its protected peer review policy to be consistent with Veterans Health Administration policy and that facility managers monitor compliance.
Closure Date:
6 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
7 We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Power of Women Embracing Recovery Program have a Class K fire extinguisher available in the kitchen used by residents.
Closure Date:
9 We recommended that Domiciliary Care for Homeless Veterans Program, Post-Traumatic Stress Disorders Residential Rehabilitation Treatment Program, and Substance Abuse Treatment Unit employees consistently perform and document contraband inspections, daily bed checks, and resident room inspections for unsecured medications and that program/unit managers monitor compliance.
Closure Date:
10 We recommended that Domiciliary Care for Homeless Veterans Program and Substance Abuse Treatment Unit managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
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| 15-04696-107 | Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
Closure Date:
2 We recommended that controlled substances inspectors consistently reconcile 1 day's dispensing from the pharmacy to each automated unit and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
3 We recommended that the facility ensure the Controlled Substances Coordinator's position description includes controlled substances oversight duties.
Closure Date:
4 We recommended that the facility ensure controlled substances inspectors receive annual updates and refresher training.
Closure Date:
5 We recommended that the Controlled Substances Coordinator ensure random scheduling of non-pharmacy area inspections with no distinguishable patterns and that facility managers monitor compliance.
Closure Date:
6 We recommended that controlled substances inspectors consistently validate transfers from one storage area to another and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
7 We recommended that controlled substances inspectors consistently verify hard copy orders for five randomly selected dispensing activities (or a minimum of two if less than five dispensing activities on the unit) and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
8 We recommended that pharmacy employees consistently perform 72-hour inventories of the main vault and that facility managers monitor compliance.
Closure Date:
9 We recommended that controlled substances inspectors consistently compare drugs held for destruction with the Destruction File Holding Report for 10 randomly selected drugs and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
10 We recommended that controlled substances inspectors consistently verify completion of drug destructions at least quarterly and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
11 We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
Closure Date:
12 We recommended that clinicians communicate incomplete or probably benign results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
Closure Date:
13 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:
14 We recommended that clinicians include the contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
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15039