Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00132-430 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the staff at theBrownwood CBOC receive regular information/updates on their responsibilities in emergency response operations.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic
assessments for patients with a positive alcohol screen.
Closure Date:
3 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:
4 We recommended that clinic staffconsistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that ClinicRegistered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that providers in theoutpatient 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 the timeframe set by local policy.
Closure Date:
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| 15-00144-426 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Iowa City VA Health Care System, Iowa City, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
5 We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results include all required elements
Closure Date:
6 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
7 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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| 15-00598-446 | Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
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 the Medical Emergency Committee review each code episode.
Closure Date:
4 We recommended that the Accident Review Board Committee share patient handling injury data.
Closure Date:
5 We recommended that the quality control policy/process 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, and a complete review of scanned documents to ensure readability and retrievability.
Closure Date:
6 We recommended that the facility clean and/or repair soiled and/or damaged wheelchairs in patient care areas or remove them from service.
Closure Date:
7 We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Controlled Substances Coordinator provide quarterly trend reports to the Facility Director.
Closure Date:
9 We recommended that controlled substances inspectors consistently inspect all required non-pharmacy areas with controlled substances and that the Controlled Substances Coordinator monitor compliance.
Closure Date:
10 We recommended that facility managers ensure the Controlled Substances Coordinator sufficiently rotates controlled substances inspectors in inspection assignments and monitor compliance.
Closure Date:
11 We recommended that controlled substances inspectors complete inspections on the same day initiated and that the Controlled Substances Coordinator monitor compliance.
Closure Date:
12 We recommended that the Facility Director ensure that the controlled substances inspection program has adequate oversight and complies with Veterans Health Administration policy.
Closure Date:
13 We recommended that Domiciliary Care for Homeless Veterans Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Closure Date:
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| 15-00596-429 | Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
2 We recommended that the Surgical Work Group meet monthly.
3 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, and a complete review of scanned documents to ensure readability and retrievability.
4 We recommended that the facility consistently document actions when data analyses indicated problems or opportunities for improvement and evaluate them for effectiveness in the Quality, Safety, and Value; Critical Care; Medical Records; and Infection Prevention and Control Committees and in the Environment of Care Council.
5 We recommended that employees offer patients the opportunity to review, revise, or rescind previously completed advance directives and document the discussions and that facility managers monitor compliance.
6 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
7 We recommended that facility managers ensure that respiratory therapy employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
8 We recommended that the facility revise the emergency airway management policy to include an alternative for new employees, transfers from other VA medical centers, consultants or without compensation clinicians, and the availability of portable video laryngoscopes for use by clinicians for emergency airway management.
9 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.
10 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.
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| 15-00602-425 | Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that pharmacy personnel conduct and document monthly medication storage area inspections and that facility managers monitor compliance.
Closure Date:
2 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:
3 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
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| 14-00903-422 | Healthcare Inspection – Quality of Care Issues, Sheridan VA Healthcare System, Sheridan, Wyoming | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that staff comply with Veterans Health Administration and facility policies and practices related to the management of dysphagia, including assessment and documentation of a patient's response to the provided care recommendations and aspiration risk precautions.
Closure Date:
2 We recommended that the Facility Director implement applicable recommendation(s) from previous event-related reviews, if any.
Closure Date:
3 We recommended that the Facility Director review local privileging processes and ensures compliance with local policy and Veterans Health Administration Handbook 1100.19.
Closure Date:
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| 15-00138-392 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Haverhill CBOC receive
the required training on hazardous materials.
Closure Date:
2 We recommended that CBOC staff minimize the risk of infection
when storing and disposing of medical (infectious waste) at the Haverhill CBOC.
Closure Date:
3 We recommended that the information technology server closet
at the Haverhill CBOC is maintained according to information technology safety and security standards.
Closure Date:
4 We recommended that testing of the panic alarm system is conducted at the Haverhill CBOC.
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 and clinical associates 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 the timeframe set by local policy.
Closure Date:
| ||||
| 15-00595-417 | Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and 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 Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, that the committee document the screening reviews, and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility include Social Work Service, Chaplain Service, and the Rehabilitation Medicine and Service Care Line in the review of electronic health record quality.
Closure Date:
5 We recommended that facility managers ensure that patient care areas are clean and in good repair and that areas under sinks are not used for storage and monitor compliance.
Closure Date:
6 We recommended that the recently implemented Consult Management Committee continue to meet regularly to review consult data.
Closure Date:
7 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and includes all required elements and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure the Domiciliary and Psychosocial Residential Rehabilitation Treatment Programs are clean and monitor compliance.
Closure Date:
10 We recommended that the Domiciliary Residential Rehabilitation Treatment Program have a Class K fire extinguisher available in the kitchen used by residents.
Closure Date:
11 We recommended that the facility correct the deficiencies identified during monthly Domiciliary Residential Rehabilitation Treatment Program self-inspections and that documentation reflects correction.
Closure Date:
12 We recommended that Domiciliary Residential Rehabilitation Treatment Program managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
13 We recommended that clinicians ensure that the safety plans for all patients assessed to be at high risk for suicide specifically address suicidality and that facility managers monitor compliance.
Closure Date:
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| 14-04037-404 | Healthcare Inspection – Vascular Surgery Resident Supervision, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure the timeframe for supervisor co-signature of inpatient resident progress notes is defined and documented.
Closure Date:
2 We recommended that the System Director ensure that attending surgeons cosign resident progress notes timely.
Closure Date:
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| 14-04754-407 | Healthcare Inspection – Alleged Colorectal Cancer Screening and Administrative Issues, VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director implement procedures to prevent the unauthorized use of individuals’ signature blocks on form letters.
Closure Date:
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15039