Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00155-16 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Battle Creek VA Medical Center, Battle Creek, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect and secure specimens and patient-identifiable information at the Muskegon VA Clinic.
Closure Date:
2 We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Muskegon VA Clinic.
Closure Date:
3 We recommended that staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Muskegon VA Clinic.
Closure Date:
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
5 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:
6 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
8 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
9 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients 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:
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| 15-00163-01 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure a safe, clean, and well maintained environment of care at the Morristown VA Clinic.
Closure Date:
2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Morristown VA Clinic.
Closure Date:
3 We recommended that all employees at the Morristown VA Clinic receive the required training on hazardous materials.
Closure Date:
4 We recommended that managers ensure that all safety inspections on medical equipment are performed as required by facility policy at the Morristown VA Clinic.
Closure Date:
5 We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Morristown VA Clinic.
Closure Date:
6 We recommended that staff are trained to properly disinfect non-critical medical equipment as required at the Morristown VA Clinic.
Closure Date:
7 We recommended that Morristown VA Clinic staff protect patient-identifiable information on laboratory specimens during transport.
Closure Date:
8 We recommended that the information technology server closet at the Morristown VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
9 We recommended that managers ensure that all staff at the Morristown VA Clinic are trained to safely evacuate using all exit routes from the building.
Closure Date:
10 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
11 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:
12 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:
13 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
14 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-00177-07 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Marion VA Medical Center, Marion, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that safety data sheets are current at the Paducah VA Clinic.
Closure Date:
2 We recommended that managers ensure staff can access the electronic version of safety data sheets at the Paducah VA Clinic.
Closure Date:
3 We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Paducah VA Clinic in accordance with Joint Commission standards.
Closure Date:
4 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Paducah VA Clinic to the parent facility.
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 Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 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:
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 notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-00622-06 | Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Cardiopulmonary Resuscitation Subcommittee review each code episode.
Closure Date:
2 We recommended that the Operating Room Management Council meet monthly, include the Chief of Staff and Surgical Quality Nurse as members, and document its review of National Surgical Office reports.
Closure Date:
3 We recommended that the Operating Room Management Council review all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
4 We recommended that the Infection Prevention and Control Sub-Committee document follow-up on actions implemented to address identified problems.
Closure Date:
5 We recommended that facility managers ensure patient care areas are clean and 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 facility managersensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
8 We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
9 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
10 We recommended that radiologists document the radiation dose in the Computerized Patient Record System and that facility managers monitor compliance.
Closure Date:
11 We recommended that employees consistently use appropriate note titles to document advance directive screening and that facility managers monitor compliance.
Closure Date:
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.
Closure Date:
13 We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
Closure Date:
15 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
16 We recommended that the facility consistently perform continuing stay reviews on at least 75 percent of patients in acute beds.
Closure Date:
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| 14-00875-03 | Healthcare Inspection – Access to Urology Service, Phoenix VA Health Care System, Phoenix, AZ | Hotline Healthcare Inspection | ||
1 We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that resources are in place to deliver timely urological care to patients.
Closure Date:
2 We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that non-VA care providers’ clinical documentation is available in the electronic health records in a timely manner for Phoenix VA Health Care System providers to review.
Closure Date:
3 We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that the cases identified in this report are reviewed, and for patients who suffered adverse outcomes and poor quality of care, confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
Closure Date:
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| 15-00506-535 | Healthcare Inspection – Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Under Secretary for Health perform a quality review of the Chief of Surgery's colonoscopies performed in the prior Veterans Health Administration facility.
Closure Date:
2 We recommended that the Acting Under Secretary for Health revise the Veterans Health Administration Colorectal Cancer Screening directive to include standardized documentation of quality indicators based on professional society guidelines and published literature (including but not limited to photodocumentation of anatomical landmarks establishing cecal intubation and documentation of cecal withdrawal times).
Closure Date:
3 We recommended that the Acting Under Secretary for Health consider adding photodocumentation of cecal intubation and cecal withdrawal time to the standardized criteria for quality colonoscopy for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation.
Closure Date:
4 We recommended that the System Director ensure patient notification of diagnostic test results within the required timeframe, particularly for critical results, and that clinicians document notification.
Closure Date:
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| 15-02053-537 | Review of Alleged Improper Pay at VHA's Hudson Valley Health Care System | Audit | ||
1 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System conducts a review of all Federal Wage Service employees’ official duty stations.
Closure Date:
2 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System takes action to correct any inappropriate Federal Wage Service employees’ official duty stations and wage rates.
Closure Date:
3 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System provides training to all management and Human Resources personnel on how to correctly determine an employee’s official duty station.
Closure Date:
4 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System develops procedures to monitor the accuracy of Federal Wage Service employees’ official duty station.
Closure Date:
5 We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review and consult appropriate VA offices, including the Office of General Counsel, to determine whether administrative action is appropriate for those officials in the Engineering, Environmental Management, and Human Resources Services who did not adequately review or correct employees’ official duty stations in response to the 2014 Office of Human Resources and Administration’s request for verification of all employees’ official duty stations.
Closure Date:
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| 15-00171-533 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Manchester VA Medical Center, Manchester, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence
Closure Date:
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| 13-04038-521 | Healthcare Inspection – Alleged Suicides and Inappropriate Changes to Mental Health Treatment Program, Coatesville VA Medical Center, Coatesville, Pennsylvania | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director coordinate with Veterans Health Administration leadership regarding the establishment of a Psychosocial Rehabilitation and Recovery Center.
Closure Date:
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| 15-02745-522 | Review of VBA's Alleged Mismanagement of Unemployability Benefits at VARO Seattle, Washington | Audit | ||
1 We recommended that the Pacific District Director convene an administrative investigation board to determine why VA Regional Office management was unaware that Intake Processing Center staff had stored unprocessed mail for several months without action.
Closure Date:
2 We recommended the Pacific District Director convene an administrative investigation board to determine why staff responsible for managing mail did not seek assistance for processing employment questionnaires for several months.
Closure Date:
3 We recommended the VA Regional Office Director conduct refresher training for staff responsible for processing mail with emphasis on processing employment questionnaires.
Closure Date:
4 We recommended the Under Secretary for Benefits implement a plan that requires audit trails coexist with corrective action plans when areas of mismanagement or data manipulation are identified at VA Regional Offices.
Closure Date:
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15039