Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-05163-106 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Coatesville VA Medical Center, Coatesville, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers provide auditory privacy for Springfield VA Clinic veterans at check-in.
Closure Date:
2 We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
Closure Date:
3 We recommended 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 within 14 days as required by VHA.
Closure Date:
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| 15-02472-46 | Review of Alleged Untimely Care at VHA’s Community Based Outpatient Clinic Colorado Springs, CO | Audit | ||
1 We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the clinically indicated or preferred appointment dates when scheduling primary care patient appointments.
Closure Date:
2 We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the earliest appropriate date when scheduling new patient appointments.
Closure Date:
3 We recommended the Eastern Colorado Health Care System Director ensure that staff place all veterans with appointments occurring over 30 days after the clinically indicated or preferred appointment date on the Veterans Choice List within 1 day of scheduling the appointment.
Closure Date:
4 We recommended the Eastern Colorado Health Care System Director ensure that resources are sufficient for scheduling staff to act on consults within 7 days and appointment requests for newly enrolled veterans within 1 day of the approved appointment request.
Closure Date:
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| 15-03026-101 | Review of Alleged Patient Scheduling Issues at the VA Medical Center in Tampa, FL | Audit | ||
1 We recommended the Director of James A. Haley Veterans’ Hospital coordinate with the responsible contracting officer to develop a mechanism to ensure the facility receives prompt notification of scheduled Veterans Choice Program appointments.
Closure Date:
2 We recommended the Director of James A. Haley Veterans’ Hospital request that the responsible contracting officer determine if Health Net complies with the modification to the Patient-Centered Community Care contract requiring the contractor to notify VA when a veteran is scheduled for an appointment through the Veterans Choice Program.
Closure Date:
3 We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services transmit all scheduling audit results to appropriate staff for awareness and corrective action.
Closure Date:
4 We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services develop a procedure to verify the schedulers properly correct identified errors.
Closure Date:
5 We recommended the Director of James A. Haley Veterans’ Hospital ensure supervisors provide additional training to schedulers regarding the management of the Veterans Choice List to ensure staff add all eligible veterans to the Veterans Choice List in a timely manner and that veterans remain on the Veterans Choice List.
Closure Date:
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| 15-04983-86 | Inspection of VA Regional Office Little Rock, Arkansas | Review | ||
1 We recommended the Little Rock VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-04706-104 | Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semiannually and that facility managers monitor compliance.
2 We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
3 We recommended that the facility ensure the Women Veterans Program Manager has sufficient allocated administrative time for oversight duties and does not provide direct patient care more than 1/8 of her time (5 hours per week).
4 We recommend that clinicians develop and document Suicide Prevention Safety Plans and that facility managers monitor compliance.
5 We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
6 We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
7 We recommended that domiciliary managers ensure the Domiciliary Care for Homeless Veterans and Substance Abuse Domiciliary has written agreements in place acknowledging resident responsibility for medication security.
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| 15-05155-89 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Western New York Healthcare System, Buffalo, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the Buffalo VA Clinic.
2 We recommended that managers document their consideration and implementation of safety needle devices.
3 We recommended that managers ensure fire drills are conducted at least every 12 months at the Buffalo VA Clinic.
4 We recommended that managers test the alarm system or panic buttons regularly at the Buffalo VA Clinic.
5 We recommended that managers maintain a clean environment of care at the Buffalo VA Clinic.
6 We recommended that managers ensure hand hygiene products are readily accessible to employees at the Buffalo VA Clinic.
7 We recommended that managers provide feminine hygiene products in women’s public restrooms at the Buffalo VA Clinic.
8 We recommended that managers at the Buffalo VA Clinic ensure all medications are secured from unauthorized access.
9 We recommended that managers at the Buffalo VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
10 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
11 We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
12 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
13 We recommended that providers ensure that PTSD patients receive mental health treatment, when applicable.
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| 15-05149-88 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that providers sign home telehealth assessments and treatment plans.
Closure Date:
2 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-04698-99 | Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York | 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.
2 We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
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.
4 We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
5 We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
6 We recommended that facility managers ensure floors in patient care areas are clean and free of mold and monitor compliance.
7 We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
8 We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes a written test and gloved fingertip sampling.
9 We recommended that the facility fully implement the newly revised compounded sterile products safety/competency assessment checklist that includes all required elements.
10 We recommended that facility managers ensure pharmacy staff remove packaging from items before transfer to the buffer room and clean and sanitize items transferred to the buffer room.
11 We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
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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| 15-00075-87 | Combined Assessment Program Follow-Up Review of the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure access to exits is unrestricted and monitor compliance.
Closure Date:
2 We recommended that facility managers ensure all nurse call system alarms are functioning and monitor compliance.
Closure Date:
3 We recommended that facility managers ensure emergency response medications and equipment are available for immediate use in patient care areas and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure electrical power strips are not plugged into other power strips and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure crash carts using electrical power strips have those strips permanently attached.
Closure Date:
6 We recommended that facility managers ensure patient care areas do not contain portable space heaters and monitor compliance.
Closure Date:
7 We recommended that the facility repair or replace the uneven and buckling flooring in the combined Domiciliary and Substance Abuse Residential Rehabilitation Treatment Program.
Closure Date:
8 We recommended that facility managers ensure compliance with Safety Data Sheet recommendations regarding chemical storage, use, and safety.
Closure Date:
9 We recommended that facility managers ensure signage identifying the location of alternative exits is posted during construction projects.
Closure Date:
10 We recommended that facility managers ensure signage is installed to clearly identify the location of fire extinguishers in large rooms and those obstructed from view.
Closure Date:
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| 14-05173-92 | Healthcare Inspection – Environment of Care and Safety Concerns in Operating Room Areas, Edward Hines Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Facility Director implement an action plan to remediate water damage in the basement of Building 200.
Closure Date:
2 We recommended that the Acting Facility Director initiate a safety analysis of the current overhead paging and emergency system for communication of a code throughout the entire surgical operating room, including the post anesthesia care units and take action as necessary.
Closure Date:
3 We recommended that the Acting Facility Director implement processes to maintain recommended ranges for temperature and humidity in operating room areas.
Closure Date:
4 We recommended that the Acting Facility Director take actions to prevent staff injury as a result of surgical booms located in operating rooms.
Closure Date:
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15039