Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00180-538 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pacific Islands Health Care System, Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers maintain a clean and functioning environment of care at the American Samoa 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 American Samoa VA Clinic.
Closure Date:
3 We recommended that managers ensure that safety data sheets are readily available to staff at the American Samoa VA Clinic.
Closure Date:
4 We recommended that hand hygiene compliance is monitored at the American Samoa VA Clinic and reported to the Infection Control Committee.
Closure Date:
5 We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious) waste at the American Samoa VA Clinic.
Closure Date:
6 We recommended that written procedures are available and staff are trained to properly disinfect non-critical medical equipment as required at the American Samoa VA Clinic.
Closure Date:
7 We recommended that the information technology server closet at the American Samoa VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
8 We recommended that panic alarms are installed and tested, and testing is documented in all high-risk areas at the American Samoa VA Clinic.
Closure Date:
9 We recommended that the staff at the American Samoa VA Clinic receive regular information/updates on their responsibilities in emergency response operations.
Closure Date:
10 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
11 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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 consistently document informed consent for human immunodeficiency virus testing 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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| 15-01590-523 | Review of Alleged Inappropriate Referrals at VHA’s Southern Nevada Healthcare System to a Non-VA Medical Provider | Audit | ||
1 We recommended the Under Secretary for Health ensure that TriWest Healthcare Alliance Corporation meets the terms of the Patient-Centered Community Care contract by referring radiation oncology patients to only American College of Radiology-accredited network practices/facilities.
Closure Date:
2 We recommended the Under Secretary for Health determine whether the Patient-Centered Community Care contract with TriWest Healthcare Alliance Corporation needs to be amended to allow referrals to other than American College of Radiology-accredited network practices/facilities.
Closure Date:
3 We recommended the Under Secretary for Health require the review of medical results for the 15 patients referred to practices/facilities not accredited by the American College of Radiology or American College of Radiation Oncology to ensure they received treatment that met Veterans Health Administration standards of care.
Closure Date:
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| 15-00620-548 | Combined Assessment Program Review of the Manchester VA Medical Center, Manchester, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 We recommended that when cases receive initial Level 2 or
3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
2 We recommended that facility managers review privilege forms annually and document the review.
3 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
4 We recommended that the Code Committee review each code episode.
5 We recommended that the Safe Patient Handling Committee meet monthly and provide oversight of the safe patient handling program.
6 We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
7 We recommended that the facility assign the Suicide Prevention Coordinator full time to suicide prevention activities.
8 We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
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| 15-00176-541 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the El Dorado VA Clinic to the parent facility or contracted processing facility.
Closure Date:
2 We recommended that the information technology server closet at the El Dorado VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
3 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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 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:
7 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
8 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:
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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| 15-01110-493 | Inspection of VA Regional Office Los Angeles, California | Review | ||
1 We recommended the Los Angeles VA Regional Office Director conduct a review of the 522 temporary 100 percent disability evaluations remaining from our inspection universe as of December 2014, and take appropriate actions.
Closure Date:
2 We recommended the Los Angeles VA Regional Office Director implement a plan to ensure oversight and prioritization of temporary 100 percent disability evaluations.
Closure Date:
3 We recommended the Los Angeles VA Regional Office Director implement a plan to monitor the effectiveness of training on traumatic brain injury claims.
Closure Date:
4 We recommended the Los Angeles VA Regional Office Director implement a plan to ensure staff comply with Veterans Benefits Administration's second-signature requirements for traumatic brain injury claims, and the local procedures for processing traumatic brain injury claims.
Closure Date:
5 We recommended the Los Angeles VA Regional Office Director provide training on higher levels of special monthly compensation for all staff members responsible for evaluating or providing second-signature reviews for these cases.
Closure Date:
6 We recommended the Los Angeles VA Regional Office Director implement a plan to ensure oversight and prioritization of benefit reduction cases.
Closure Date:
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| 15-00605-544 | Combined Assessment Program Review of the VA Maine Healthcare System, Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director chair or co-chair the Performance Improvement Board.
Closure Date:
2 We recommended that facility managers review privilege forms annually and document the review.
Closure Date:
3 We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassess observation criteria and utilization.
Closure Date:
4 We recommended that the Special Care Unit Committee review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
5 We recommended that the facility consistently include most services in the review of electronic health record quality.
Closure Date:
6 We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, a complete review of scanned documents to ensure readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
Closure Date:
7 We recommended that facility managers ensure patient care areas are clean and damaged wall surfaces are repaired and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure the walkway from the handicapped parking area to the main entrance is repaired.
Closure Date:
9 We recommended that employees promptly remove expired or undated medications from patient care areas and that facility managers monitor compliance.
Closure Date:
10 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
11 We recommended that the facility develop a written policy for safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
Closure Date:
12 We recommended that the facility create/designate a committee to oversee consult management.
Closure Date:
13 We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
Closure Date:
14 We recommended that employees consistently correctly post patients' advance directives status and that facility managers monitor compliance.
Closure Date:
15 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
16 We recommended that facility managers ensure that special care unit nurses have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
17 We recommended that the facility revise the emergency airway management policy to include the availability of portable video laryngoscopes, the use of a device to confirm endotracheal tube placement in conjunction with auscultation, and a plan for managing the difficult airway.
Closure Date:
18 We recommended that facility managers ensure completion of initial assessments for emergency airway management competency prior to the clinicians providing coverage.
Closure Date:
19 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
Closure Date:
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| 15-00617-539 | Combined Assessment Program Review of theWilliam S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
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| 15-00574-501 | Review of Patient-Centered Community Care (PC3) Health Record Coordination | Audit | ||
1 We recommended the Under Secretary for Health implement a mechanism to ensure payments are not made to Patient-Centered Community Care contractors until all required clinical documentation is received.
Closure Date:
2 We recommended the Under Secretary for Health enforce Patient-Centered Community Care contract performance requirements to ensure that contractors return complete clinical documentation timely.
Closure Date:
3 We recommended the Under Secretary for Health implement a mechanism to verify contractors¿ performance without relying on contractors¿ self-reported data.
Closure Date:
4 We recommended the Under Secretary for Health complete a review of TriWest's performance and apply penalties if it is determined there is a lack of performance related to the timely return of clinical documentation.
Closure Date:
5 We recommended the Under Secretary for Health review the contract disincentives applied to HealthNet and determine if additional funds need to be recouped from the contractor and pursue collection if disincentives were under applied.
Closure Date:
6 We recommended the Under Secretary for Health ensure that Patient-Centered Community Care contractors annotate on all diagnostic imaging reports and non-imaging-related critical findings submitted to VA the name of the VA person contacted, and the date and time of the contact.
Closure Date:
7 We recommended the Under Secretary for Health implement procedures to verify whether Patient-Centered Community Care contractors and their network providers correctly and timely report critical findings to VA and impose financial penalties or other remedies when contractors fall below the contract performance threshold.
Closure Date:
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| 15-00616-543 | Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee.
Closure Date:
2 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management are granted privileges to perform the procedure.
Closure Date:
3 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
Closure Date:
4 We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies and include corrective actions and tracking of actions to closure.
Closure Date:
5 We recommended that facility managers ensure employees initiate corrective actions when sterile supply room temperature and/or humidity values are out of range and monitor compliance.
Closure Date:
6 We recommended that the facility repair or replace damaged paper towel dispensers in patient and public restrooms and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility repair damaged patient equipment and furnishings or remove them from service and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure crash cart logs contain the correct lock number and monitor compliance.
Closure Date:
10 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
11 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
12 We recommended that employees follow up with inpatients who would like to discuss creating, changing, and/or revoking advance directives to ensure the discussion takes place and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements 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 all required competency elements prior to being assigned coverage.
Closure Date:
15 We recommended that facility managers ensure video laryngoscopes are available in all designated locations at the Lyons campus and monitor compliance.
Closure Date:
16 We recommended that facility managers ensure that the Domiciliary Care for Homeless Veterans Program has signage alerting veterans and visitors of closed circuit television recording.
Closure Date:
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| 15-00718-507 | Review of VHA's Patient-Centered Community Care (PC3) Provider Network Adequacy | Audit | ||
1 We recommended the Under Secretary for Health ensure the establishment of an adequate governance structure to oversee and improve Patient-Centered Community Care management and operations.
Closure Date:
2 We recommended the Under Secretary for Health ensure adequate implementation and performance monitoring plans are developed for future high-dollar, complex health care initiatives.
Closure Date:
3 We recommended the Under Secretary for Health assess where Patient-Centered Community Care provider networks are inadequate and develop action plans to improve provider networks that are unable to provide health care services at the specific geographic locations identified.
Closure Date:
4 We recommended the Under Secretary for Health ensure the Patient-Centered Community Care Quality Assurance Surveillance Plan is revised to address the monitoring and measurement of network adequacy.
Closure Date:
5 We recommended the Under Secretary for Health require the input of National Provider Identifier information for rendering providers in the Fee Basis Claims System to ensure adequate data are available for program evaluation and planning.
Closure Date:
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15039