Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-02400-524 | Review of Alleged Beneficiary Travel Irregularities at Hudson Valley HCS, Hampton & Lexington VAMCs | Audit | ||
1 We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System complies with VHA Procedure Guide requirements to use the Beneficiary Travel Dashboard to calculate mileage as the basis for reimbursement.
2 We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System’s and the Hampton Veterans Affairs Medical Center’s Beneficiary Travel Dashboards are configured to assist staff in identifying the nearest facility able to provide care or services as the basis for mileage reimbursements.
3 We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers strengthen Beneficiary Travel Program processing accuracy by developing a formal plan to routinely identify staff training needs and provide appropriate training.
4 We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers develop and implement a formal process to routinely identify Beneficiary Travel Program mileage reimbursement processing deficiencies and apply corrective actions.
5 We recommended the Under Secretary for Health requires the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers to determine whether the improper payments identified by our review warrant establishing bills of collection or reimbursing beneficiaries, when applicable.
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| 15-00628-49 | Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
2 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
3 We recommended the Critical Care Committee continue the recently implemented process that includes screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
4 We recommended that facility managers ensure that damaged wheelchairs are repaired or removed from service and that wheelchairs are included in the facility’s preventative maintenance program.
5 We recommended that facility managers ensure that employees follow facility policy for disinfection of non-critical equipment between patients and that exam rooms contain adequate supplies for disinfection.
6 We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
7 We recommended that facility managers ensure patient-specific insulin vials distributed to units are consistently labeled with correct expiration dates and monitor compliance.
8 We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
9 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
10 We recommended that facility managers ensure that surgical intensive care unit nurses have 12-lead electrocardiogram and post-anesthesia care competency assessment and validation included in their competency checklists.
11 We recommended that the facility ensure that initial clinician emergency airway management competency assessment includes all required subject matter content elements and evidence of a completed written test and that facility managers monitor compliance.
12 We recommended that the facility ensure that initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
13 We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
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| 15-03804-38 | Combined Assessment Program Summary Report – Evaluation of Magnetic Resonance Imaging Safety 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 employees consistently conduct initial magnetic resonance imaging patient safety screenings.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel consistently document when they review the second magnetic resonance imaging patient safety screening forms.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel document resolution of all identified potential contraindications prior to the magnetic resonance imaging exam.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities routinely conduct contrast reaction drills in magnetic resonance imaging areas.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that all designated Level 1 ancillary employees receive annual level-specific magnetic resonance imaging safety training.
Closure Date:
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| 15-00157-39 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Oklahoma City VA Health Care System, Oklahoma City, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Stillwater VA Clinic.
Closure Date:
2 We recommended that signage is installed at the Stillwater VA Clinic to clearly identify the location of the fire extinguisher in the lobby area.
Closure Date:
3 We recommended that clinic staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Stillwater VA Clinic.
Closure Date:
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
8 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
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| 15-03803-26 | Combined Assessment Program Summary Report – Evaluation of Acute Ischemic Stroke Care in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health improve the availability of expertise in stroke treatment across the system.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure compliance with stroke care requirements, including prompt and thorough assessment, treatment, and patient education, and ensure the gathering and reporting of required stroke data elements.
Closure Date:
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| 14-01910-459 | Healthcare Inspection – Quality of Care Concerns at a Residential Rehabilitation Treatment Program, VA Maryland HCS, Baltimore, MD | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program medical providers document pertinent information related to medical decision-making in the electronic health record and monitor compliance.
Closure Date:
2 We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program managers review and address medical provider staffing needs in the Mental Health Residential Rehabilitation Treatment Program.
Closure Date:
3 We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program staff complete all required elements of the safe medication management program.
Closure Date:
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| 14-02576-40 | Healthcare Inspection – Point of Care Testing Program Concerns, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that point of care testing policies related to proper identification of patients and test operators comply with Veterans Health Administration requirements including all accreditation and regulatory standards incorporated in these requirements.
Closure Date:
2 We recommended that the Facility Director enforce point of care testing policies to include the management process to track issues of error and system misuse and follow them to resolution.
Closure Date:
3 We recommended that the Facility Director ensure that all users of point of care testing equipment complete orientation and ongoing training and competency assessments in accordance with facility and Veterans Health Administration policy, to include contract employees and students.
Closure Date:
4 We recommended that the Facility Director evaluate circumstances when sharing or misuse of barcode identifiers became an ongoing practice, in violation of policy, and confer with the Office of Human Resources and the Office of General Counsel to determine appropriate administrative action, if any.
Closure Date:
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| 15-00179-34 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Southern Nevada Healthcare System, North Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient identifiable information on laboratory specimens during transport from the Southeast VA Clinic to the parent facility or contracted processing facility.
Closure Date:
2 We recommended that panic alarm testing documentation includes specific testing locations at the Southeast VA Clinic.
Closure Date:
3 We recommended that managers at the Southeast VA Clinic maintain attendance records to verify staff participation during emergency management training and exercises.
Closure Date:
4 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
10 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
11 We recommended that clinicians document in the electronic health record all attempts to communicate laboratory results with the patients.
Closure Date:
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| 15-00625-37 | Combined Assessment Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management receive the appropriate training.
Closure Date:
2 We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
Closure Date:
3 We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies and specifics, including the deficiency, location, action, and resolution and any trends.
Closure Date:
4 We recommended that facility managers monitor the use of clean biohazard bags to ensure they are used appropriately.
Closure Date:
5 We recommended that facility managers ensure designated employees receive emergency evacuation device training and competency assessment and revise the local policy to define expectations for competency assessment.
Closure Date:
6 We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
7 We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and on the intensive care-step down unit and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
8 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility revise the local policy to address advance directive notification, screening, and discussions.
Closure Date:
10 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:
11 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:
12 We recommended that Radiology Service revise its policies to require a 30-minute on-call reporting time for computed tomography scans and a 30-minute on-call response time for radiology interpretation.
Closure Date:
13 We recommended that the facility ensure clinicians complete all required emergency airway management competency reassessment elements prior to providing emergency airway management coverage and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility have appropriate emergency airway management coverage during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers ensure that identified deficiencies from the annual pharmacy physical security survey are corrected and monitor compliance.
Closure Date:
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| 15-00624-31 | Combined Assessment Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate training.
Closure Date:
2 We recommended that Intensive Care Unit Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code and that the committee documents the reviews.
Closure Date:
3 We recommended that the Surgical Work Group meet monthly.
Closure Date:
4 We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
Closure Date:
5 We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter.
Closure Date:
6 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:
7 We recommended that facility managers ensure that employees on the medical-surgical and intensive care units and in the Emergency Department have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
8 We recommended that facility managers ensure that intensive care unit employees have post-anesthesia care competency assessment and validation completed and documented.
Closure Date:
9 We recommended that the facility ensure emergency airway management competency is completed at the time of initial privileges and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility ensure clinicians complete all required competency elements prior to the granting or renewal of
privileges or scope of practice and that facility managers monitor compliance.
Closure Date:
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15039