Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00069-199 | Combined Assessment Program Review of the VA Puget Sound Health Care System, Seattle, Washington | 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.
Closure Date:
2 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:
3 We recommended that the Surgical Work Group include the Chief of Staff as a member.
Closure Date:
4 We recommended that the Safe Patient Handling Committee track patient handling injury data.
Closure Date:
5 We recommended the facility ensure a third party conducts quality assurance reviews on a sample of the scanned documents.
Closure Date:
6 We recommended that Environment of Care Board and Safety Committee minutes include corrective actions to address identified deficiencies and track those actions to closure.
Closure Date:
7 We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure community living center treatment carts containing resident care supplies are clean and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure critical medical equipment in the community living center is plugged into outlets that function in the event of a power loss and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
Closure Date:
11 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
13 We recommended that nursing reviewers sign the monthly medication review forms and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility’s recently chartered Consult Management Committee meet regularly and document oversight of consult management.
Closure Date:
15 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
16 We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
18 We recommended that Level 2 magnetic resonance imaging personnel review and sign secondary patient safety screening forms prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
19 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:
20 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:
21 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
22 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:
23 We recommended that facility managers ensure the American Lake division follows local emergency airway management policy, or if the facility plans to perform intubations in areas designated to call 911, the facility updates the local emergency airway management policy and ensures privileged providers or clinicians with emergency airway management scope of practice are available.
Closure Date:
24 We recommended that facility managers ensure reporting of emergency airway management data to the designated committee with the frequency required by local policy.
Closure Date:
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| 15-00072-160 | Combined Assessment Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Environment of Care Committee gather, track, and share patient handling injury data.
Closure Date:
2 We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
4 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
5 We recommended that the facility conduct contrast reaction drills in magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
6 We recommended that the facility ensure all designated Level 1 ancillary staff and all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
7 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:
8 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
9 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
10 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:
11 We recommended that the facility collect and 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:
12 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility mangers monitor compliance.
Closure Date:
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| 15-00071-158 | Combined Assessment Program Review of the West Palm Beach VA Medical Center, West Palm Beach, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that emergency airway management privileges granted are appropriate for the practitioners' skills and training.
Closure Date:
2 We recommended that the Cardiopulmonary Resuscitation 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:
3 We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document did not meet image quality controls and a correction process if scanned items have errors.
Closure Date:
4 We recommended that Environment of Care Committee minutes include consistent discussion of rounds deficiencies, trends, and actions and tracking of actions to closure.
Closure Date:
5 We recommended that infection prevention and control meeting minutes consistently reflect discussion of identified high-risk priority areas.
Closure Date:
6 We recommended that facility managers ensure patient care areas and public restrooms are clean and toilet paper dispensers are in good repair and monitor compliance.
Closure Date:
7 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility secure medication carts when not in use and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
10 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
12 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility update the local consult policy for policy changes and review the policy at least every 3 years and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility conduct contrast reaction and fire emergency drills in magnetic resonance imaging and that the facility managers monitor compliance.
Closure Date:
15 We recommended that the facility conduct initial patient safety screenings and that the facility managers monitor compliance.
Closure Date:
16 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 the facility managers monitor compliance.
Closure Date:
17 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:
18 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
19 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:
20 We recommended that facility managers ensure that all nursing employees who perform 12-lead electrocardiograms have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
21 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the 2B-ICU.
Closure Date:
22 We recommended that the facility revise the emergency airway management policy to include a specific plan to manage difficult airways.
Closure Date:
23 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements, including a written test, and that facility managers monitor compliance.
Closure Date:
24 We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Closure Date:
25 We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
Closure Date:
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| 14-03927-197 | Healthcare Inspection – Patient Telemetry Monitoring Concerns, Michael E. DeBakey VA Medical Center, Houston, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the appropriateness of assigning patients to telemetry is reviewed.
Closure Date:
2 We recommended that the Facility Director ensure dedicated wireless telephones are continuously carried by unit charge nurses or designees for effective communication between unit and telemetry monitoring technicians as required by local policy.
Closure Date:
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| 15-00108-194 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Martinsburg VA Medical Center, Martinsburg, West Virginia | 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 Fort Detrick CBOC.
Closure Date:
2 We recommended that employees at the Fort Detrick CBOC receive the required training on hazardous materials.
Closure Date:
3 We recommended that personal protective equipment is available for all staff at the Fort Detrick CBOC.
Closure Date:
4 We recommended that staff protect patient-identifiable information on laboratory specimens at the Fort Detrick CBOC.
Closure Date:
5 We recommended that the information technology server closet at the Fort Detrick CBOC is maintained according to information technology safety and security standards.
Closure Date:
6 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within the time frame specified in VHA policy.
Closure Date:
8 We recommended that all providers and clinical associates in the outpatient clinics receive health coaching training within the time frame specified in VHA policy.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-04391-162 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Ann Arbor Healthcare System, Ann Arbor, Michigan | 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 Jackson VA Outpatient Clinic.
Closure Date:
2 We recommended that employees at the Jackson VA Outpatient Clinic receive the required training on hazardous materials.
Closure Date:
3 We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Jackson VA Outpatient Clinic.
Closure Date:
4 We recommended that fire drills are performed every 12 months at the Jackson VA Outpatient Clinic.
Closure Date:
5 We recommended that the information technology server closet at the Jackson VA Outpatient Clinic is maintained according to information technology safety and security standards.
Closure Date:
6 We recommended that the staff at the Jackson VA Outpatient Clinic receive regular information/updates on their responsibilities in emergency response operations.
Closure Date:
7 We recommended that the staff at the Jackson VA Outpatient Clinic participate in scheduled emergency management training and exercises.
Closure Date:
8 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
9 We recommended that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
10 We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
11 We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
Closure Date:
12 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
13 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 15-00113-161 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of West Palm Beach VA Medical Center, West Palm Beach, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Delray Beach, FL, CBOC and that compliance is monitored.
Closure Date:
2 We recommended that patient-identifiable information on laboratory specimens is protected during transport from the Delray Beach, FL, CBOC to the parent facility.
Closure Date:
3 We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Delray Beach, FL, CBOC.
Closure Date:
4 We recommended that 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:
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 document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-02139-156 | Healthcare Inspection – Suicide Risk and Alleged Medical Management Issues, Hampton VA Medical Center, Hampton, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that contracted providers in all patient care areas complete the Veterans Health Administration’s suicide risk management training.
2 We recommended that the Facility Director ensure development of a process to measure the effectiveness of Veterans Health Administration required suicide risk management training for all staff members who have completed it and to provide remedial training when needed.
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| 15-01809-163 | Combined Assessment Program - Evaluation of Coordination of Care in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians provide and document discharge instructions for all identified needs and that facility managers monitor compliance.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reassess patients¿ learning needs prior to providing important instructions, including discharge instructions, and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reconcile conflicting needs and instructions before discharging patients and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that patients receive ordered post-discharge referrals and that facility managers monitor compliance.
Closure Date:
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| 14-02383-175 | Audit of VA's Drug-Free Workplace Program | Audit | ||
1 We recommended the Deputy Assistant Secretary for Human Resources Management ensure that all final selectees for Testing Designated Positions complete pre-employment drug testing prior to appointment.
Closure Date:
2 We recommended the Deputy Assistant Secretary for Human Resources Management collect data that would ensure accountability that all employees selected for random drug testing are tested.
Closure Date:
3 We recommended the Deputy Assistant Secretary for Human Resources Management develop procedures to ensure the Drug Testing coding of employees in Testing Designated Positions is accurate and complete in the Personnel and Accounting Integrated Data system.
Closure Date:
4 We recommended the Deputy Assistant Secretary for Human Resources Management coordinate with the Under Secretary for Health to implement procedures to ensure Custody and Control forms are accurately completed.
Closure Date:
5 We recommended the Deputy Assistant Secretary for Human Resources Management implement processes to adequately monitor local compliance with VA's Drug-Free Workplace Program requirements.
Closure Date:
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15039