Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00143-372 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of North Florida/South Georgia Veterans Health System, Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 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:
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 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:
4 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coach training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days, per local and VHA policy.
Closure Date:
| ||||
| 15-00131-373 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Chillicothe VA Medical Center, Chillicothe, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that signage is installed at the Marietta CBOC to clearly identify the location of fire extinguishers obscured from view.
Closure Date:
2 We recommended that the information technology server closet at the Marietta CBOC is maintained according to information technology safety and security standards.
Closure Date:
3 We recommended that Clinic Registered Nurse Managers receive motivational interviewing and health coaching training within the time frame specified by VHA policy.
Closure Date:
4 We recommended that providers in the outpatient clinics receive health coaching training within the timeframe specified by VHA policy.
Closure Date:
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently notify patients of their lab results within 14 days as required by VHA.
Closure Date:
| ||||
| 15-02627-386 | Healthcare Inspection – Alleged Poor Mental Health Care Resulting in a Patient Death, VA Central Iowa Health Care System, Des Moines, Iowa | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health determine the feasibility and advisability of expanding recovery coordination activities to patients with post-traumatic stress disorder.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that the VA Central Iowa Health Care System Director provides all levels of Operation Enduring Freedom/Operation Iraqi Freedom case management services in accordance with Veterans Health Administration policy.
Closure Date:
| ||||
| 15-00125-367 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina | 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:
2 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:
3 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:
4 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
| ||||
| 15-00128-359 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Phoenix VA Health Care System, Phoenix, Arizona | 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 Southeast VA CBOC.
2 We recommended that hand hygiene compliance is monitored at the Southeast VA CBOC and reported to the Infection Control Committee.
3 We recommended that examination tables and curtains provide adequate privacy for women veterans at the Southeast VA CBOC.
4 We recommended that the information technology server closets at the Southeast VA CBOC are maintained according to information technology safety and security standards.
5 We recommended that the staff at the Southeast VA CBOC participate in scheduled emergency management training.
6 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
7 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.
8 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.
9 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.
10 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.
11 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
| ||||
| 14-04220-363 | Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group include the Chief of Staff as a member.
Closure Date:
2 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
Closure Date:
3 We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients¿ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
5 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
7 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
10 We recommended that clinicians obtain cardiac markers, partial thromboplastin time, and an electrocardiogram while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure that medicine/telemetry unit employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.
Closure Date:
| ||||
| 15-00127-357 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Sierra Nevada Health Care System, Reno, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic alarms are tested and testing is documented at the Reno East Campus CBOC.
Closure Date:
2 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:
3 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
| ||||
| 15-00911-362 | Healthcare Inspection - Review of Solo Physicians’ Professional Practice Evaluations in Veterans Health Administration Facilities | National Healthcare Review | ||
1 We recommended that the Interim Under Secretary for Health ensure that gastroenterology, pathology, nuclear medicine, and radiation oncology program offices define specialty specific criteria or monitors for use in Focused and Ongoing Professional Practice Evaluations and require consistent application across the Veterans Health Administration and that program offices monitor compliance.
Closure Date:
2 We recommended that the Interim Under Secretary for Health require a process to obtain input for evaluating professional practice from another physician in the same specialty when a physician is the only one of any specialty at a facility and require each Veterans Integrated Service Network to monitor compliance.
Closure Date:
| ||||
| 15-00078-364 | Combined Assessment Program Review of the VA Boston Healthcare System, Boston, 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 develop a plan to complete the conversion from a six-part credentialing and privileging folder to a two-part privileging folder.
Closure Date:
3 We recommended that the facility repair damaged floors, ceilings, and walls in patient care areas.
Closure Date:
4 We recommended that facility managers ensure all patient care areas are clean and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure that all furnishings on the acute behavioral health unit comply with the standards of the VA Mental Health Environment of Care Checklist and monitor compliance.
Closure Date:
6 We recommended that the facility repair damaged or worn furnishings in patient care areas or remove them from service.
Closure Date:
7 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure all designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure that oral syringes are available for oral liquid medication administration and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
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 the facility revise the stroke policy to require the stroke team to respond in person within 30 minutes of receiving a call and that facility managers fully implement the revised policy.
Closure Date:
12 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
Closure Date:
13 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
14 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
Closure Date:
16 We recommended that facility managers ensure that A2 and 3N nurses have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.
Closure Date:
| ||||
| 15-00079-358 | Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada | Hotline Healthcare Inspection | ||
1 We recommended that the Intensive 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:
2 We recommended that the Environment of Care Committee share patient handling injury data with the newly designated safe patient handling coordinator/champion.
Closure Date:
3 We recommended that the facility establish a committee to provide oversight and coordination of electronic health record quality review activities.
Closure Date:
4 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
Closure Date:
5 We recommended that facility managers ensure patient care equipment items and surfaces are clean and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure all designated critical care employees receive annual bloodborne pathogens training and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure walk-off sticky mats are changed as needed to minimize dust and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure that the temporary construction barrier is equipped with a self-closing door with a metal frame for worker access.
Closure Date:
9 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility educate employees on the medical and community living center units that intravenous syringes are not to be used to measure oral liquid medications and that facility managers monitor compliance.
Closure Date:
11 We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
12 We recommended that the facility implement an acute ischemic stroke policy that addresses all required items.
Closure Date:
13 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
Closure Date:
14 We recommended that facility managers post stroke guidelines in all required patient care areas.
Closure Date:
15 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
16 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
18 We recommended that the facility ensure that a qualified physician is present in the Emergency Department at all times, that non-Emergency Department clinicians are assigned inpatient emergency airway management coverage from 9:00 p.m. to 7:00 a.m., and that facility managers monitor compliance.
Closure Date:
19 We recommended that the facility ensure patients with positive colorectal cancer screening test results receive diagnostic testing within the required timeframe and that facility managers monitor compliance.
Closure Date:
| ||||
15039