Recommendations
2147
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00025-301 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Carl Vinson VA Medical Center, Dublin, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that Milledgeville VA Clinic staff participate in emergency management training and exercises.
Closure Date:
2 We recommended that the clinic manager ensures that Milledgeville VA Clinic and contracted employees receive the required hazardous communications training.
Closure Date:
3 We recommended that the Milledgeville VA Clinic manager ensures that there are no expired injectable medication vials.
Closure Date:
4 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:
5 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
6 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
Closure Date:
7 We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Closure Date:
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| 16-00024-299 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of James H. Quillen VA Medical Center, Mountain Home, Tennessee | 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 the timeframe set by local policy.
Closure Date:
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| 15-01599-289 | Healthcare Inspection – Quality of Care Concerns in the Management of a Hepatitis C Patient, Grand Junction Veterans Health Care System, Grand Junction, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure adequate consultation, formalized back up, and contingency plans for specialties with limited specialty provider availability.
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| 16-00020-303 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the Monroe County VA Clinic.
Closure Date:
2 We recommended that the Facility Director ensures annual review of the Hazard Vulnerability Assessment for the Monroe County VA Clinic.
Closure Date:
3 We recommended that the clinic manager ensures that sterile commercial supplies at the Monroe County VA Clinic are not expired.
Closure Date:
4 We recommended that the clinic manager reviews the Monroe County Clinic's hazardous materials inventory twice within a 12-month period.
Closure Date:
5 We recommended that the Monroe County VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
Closure Date:
6 We recommended that clinicians document contact with patients to evaluate suitability for Home Telehealth services.
Closure Date:
7 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days.
Closure Date:
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| 16-00101-300 | Combined Assessment Program Review of the VA Greater Los Angeles Healthcare System, Los Angeles, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the senior-level committee responsible for key quality, safety, and value functions be chaired or co-chaired by the Facility Director.
Closure Date:
2 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
Closure Date:
3 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:
4 We recommended that facility managers consistently follow actions taken when data analyses indicated problems or opportunities for improvement to resolution in the Inpatient Operations Council, Medical Executive Committee, and Medical Records Committee.
Closure Date:
5 We recommended that senior managers become involved in quality, safety, and value activities.
Closure Date:
6 We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
Closure Date:
7 We recommended that employees secure medication carts and automated dispensing machines when not in use and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure pharmacy technicians complete all competency components annually and monitor compliance.
Closure Date:
9 We recommended that employees monitor temperature in the compounding areas at the Sepulveda pharmacy and that facility managers monitor compliance.
Closure Date:
10 We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
Closure Date:
11 We recommended that employees monitor temperature in the compounding areas at the Sepulveda pharmacy and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure new non-clinical employees receive suicide prevention training and new clinical employees receive suicide risk management training and monitor compliance.
Closure Date:
13 We recommended that employees complete the required reports and reviews regarding patients who attempt or complete suicide and that facility managers monitor compliance.
Closure Date:
14 We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
Closure Date:
15 We recommended that clinicians include contact numbers of family or friends for support and 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:
16 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:
17 We recommended that treatment teams follow up with patients at least four times during the first 30 days after discharge and that facility managers monitor compliance.
Closure Date:
18 We recommended that the Medical Records Committee provide oversight and coordination of the review of the quality of entries in electronic health records.
Closure Date:
19 We recommended that representatives from Surgery Service consistently attend Blood Usage Committee meetings.
Closure Date:
20 We recommended that facility managers ensure all designated employees complete annual N95 respirator fit testing and monitor compliance.
Closure Date:
21 We recommended that facility managers initiate actions to address identified security deficiencies and ensure correction of all deficiencies identified during annual physical security surveys.
Closure Date:
22 We recommended that facility managers ensure all patients discharged with pressure ulcers receive dressing supplies prior to being discharged and monitor compliance.
Closure Date:
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| 16-00010-302 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Greater Los Angeles Healthcare System, Los Angeles, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Gardena 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 Gardena VA Clinic participate in emergency management training and exercises.
Closure Date:
3 We recommended that the clinic manager ensures that Gardena VA Clinic employees receive the required hazardous communications training.
Closure Date:
4 We recommended that the clinic manager review the Gardena VA Clinic’s hazardous materials inventory twice within a 12-month period.
Closure Date:
5 We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
Closure Date:
6 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:
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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| 15-02376-239 | Review of Alleged Manipulation of Quality Review Results at VA Regional Office San Diego, CA | Audit | ||
1 We recommended that the San Diego VA Regional Office Director develop and implement a plan that provides management oversight to ensure staff comply with local policy to correct individual quality review errors.
Closure Date:
2 We recommended that the San Diego VA Regional Office Director develop and implement a plan to ensure staff work through the remaining backlog of individual quality review errors pending correction.
Closure Date:
3 We recommended that the Under Secretary for Benefits establish a timeliness standard in which claims processing staff at VA Regional Offices are expected to correct errors identified by Quality Review Team staff.
Closure Date:
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| 15-02459-260 | Review of Alleged Lack of Access Controls for VA's Project Management Accountability System (PMAS) Dashboard | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology create read-only access capability for the Project Management Accountability System.
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology assess the current level of each user’s access to the Project Management Accountability System Dashboard to ensure each user’s access is based on the least privilege needed.
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology develop Project Management Accountability System Dashboard access logs.
Closure Date:
4 We recommended the Assistant Secretary for Information and Technology periodically review Project Management Accountability System Dashboard access logs to ensure users have a need for system access.
Closure Date:
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| 14-02890-286 | Healthcare Inspection – Alleged Improper Management of Dermatology Requests, Fayetteville VA Medical Center, Fayetteville, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director follow up on the 143 patients referenced in this report who did not receive dermatology care after their appointments or consults were cancelled, and take appropriate action.
Closure Date:
2 We recommended that the facility Director follow up on all the patients with cancelled dermatology appointments and consultations in 2011–2012 who were not subsequently seen by a dermatology provider to determine whether the requested evaluation and/or care is still needed.
Closure Date:
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| 16-00108-274 | Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama | 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 facility annually assess the competency of pharmacy employees who prepare compounded sterile products and that facility managers monitor compliance.
Closure Date:
3 We recommended that facility managers ensure employees perform and document monthly cleaning of storage shelving in all compounding areas and monitor compliance.
Closure Date:
4 We recommended that the facility revisethe radiation safety policy to include a computed tomography quality control program with annual program monitoring by a medical physicist, image quality monitoring, and scanner maintenance; computed tomography protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer; a process for managing/reviewing computed tomography protocols and procedures to follow when revising protocols; and radiologist review of appropriateness of computed tomography orders.
Closure Date:
5 We recommended that facility managersconfirm computed tomography technologists have computed tomography certification prior to hiring them and ensure all current computed tomography technologists hired after July 1, 2014, have the certification.
Closure Date:
6 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:
7 We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure Focused Professional Practice Evaluations for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
Closure Date:
9 We recommended that facility managers ensure Sterile Processing Service employees responsible for reprocessing activities receive annual competency assessments.
Closure Date:
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15431