Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00116-191 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Lima CBOC.
Closure Date:
2 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Lima CBOC and that compliance is monitored.
Closure Date:
3 We recommended that processes are strengthened at the Lima CBOC to ensure that women veterans can access gender-specific restrooms without entering public areas at the Lima CBOC.
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 consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
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 document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-04623-120 | Inspection of VA Regional Office Manchester, New Hampshire | Review | ||
1 We recommended the Manchester VA Regional Office Director conduct a review of the 111 temporary 100 percent disability evaluations remaining from their inspection universe as of August 21, 2014, and take appropriate action.
Closure Date:
2 We recommended the Manchester VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations.
Closure Date:
3 We recommended the Manchester VA Regional Office Director enforce Veterans Benefits Administration's second-signature review policy for traumatic brain injury rating decisions.
Closure Date:
4 We recommended the Manchester VA Regional Office Director enforce the VARO's second signature review policy for special monthly compensation and ancillary benefits rating decisions.
Closure Date:
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| 14-04622-150 | Inspection of VA Regional Office Fargo, North Dakota | Review | ||
1 We recommended the Fargo VA Regional Office Director provide training and assess the effectiveness of that training, to ensure staff properly establish permanent disability evaluations when required.
Closure Date:
2 We recommended the Fargo VA Regional Office Director conduct a review of the 40 temporary 100 percent disability evaluations remaining from their universe as of August 21, 2014, and take appropriate action.
Closure Date:
3 We recommended the Fargo VA Regional Office Director implement a plan to ensure staff address all pending issues related to SMC and ancillary benefits.
Closure Date:
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| 15-00880-157 | Review of Alleged Data Manipulation at VA Regional Office Honolulu, HI | Audit | ||
1 We recommended the Honolulu VA Regional Office Director take immediate action to fully review and correct, as appropriate, all improper actions taken by the supervisor.
Closure Date:
2 We recommended the Honolulu VA Regional Office Director ensure staff receive training on the proper procedures for processing dependency questionnaires.
Closure Date:
3 We recommended the Honolulu VA Regional Office Director confer with Regional Counsel and human resources to determine the appropriate administrative action to take, if any, against this employee.
Closure Date:
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| 14-00730-170 | Administrative Investigation, Prohibited Personnel Practice and Misuse of VA Time and Resources, Veterans Health Administration, Chief Business Office Purchased Care, Denver, CO | Administrative Investigation | ||
1 We recommend that the Acting Deputy Under Secretary for Health for Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate corrective action to take, if any, concerning the prohibited personnel practice and improper use of a non-competitive hiring authority to reinstate Mr. Sigley.
Closure Date:
2 We recommend that the Acting Principal Deputy Under Secretary for Health (PDUSH) confer with OHR and OGC to determine the appropriate administrative action to take, if any, against (redacted).
Closure Date:
3 We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against (redacted).
Closure Date:
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| 15-00794-151 | Healthcare Inspection - Delay of Care, Goshen Community Based Outpatient Clinic, Goshen, Indiana | Hotline Healthcare Inspection | ||
1 We recommended that the VA Northern Indiana Health Care System Director ensure a review of this patient's care is conducted.
Closure Date:
2 We recommended that the VA Northern Indiana Health Care System Director ensure Goshen Community Based Outpatient Clinic patients are aware of the process for contacting a VA Northern Indiana Health Care System Patient Advocate when concerns regarding provider communication or access to medical care arise.
Closure Date:
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| 14-02437-117 | Healthcare Inspection – Staffing and Quality of Care Issues in the Community Living Center, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director require that all nursing staff in the Community Living Center receive the required training on the use of the wound vacuum assisted closure device.
Closure Date:
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| 14-04394-145 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA San Diego Healthcare System, San Diego, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
4 We recommended that providers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
6 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
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| 14-04227-147 | Combined Assessment Program Review of the VA San Diego Healthcare System, San Diego, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Procedure and Anesthesia Care Council include the Chief of Staff and Surgical Quality Nurse as members.
Closure Date:
2 We recommended that the facility analyze electronic health record quality data at least quarterly.
Closure Date:
3 We recommended that the quality control policy for scanning include the quality of the source document and alternative means of capturing data when the quality of the source document does not meet image quality controls.
Closure Date:
4 We recommended that the facility implement actions to address all high-risk areas and follow up on those actions and ensure Infection and Environmental Control Committee meeting minutes document this.
Closure Date:
5 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
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 the facility consistently 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:
8 We recommended that the facility educate employees that intravenous syringes are not to be used to measure oral liquid medications and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility ensure that multi-dose injector pens are not stored as ward stock in patient care areas and that they contain patient specific labels and that facility managers 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 the facility complete secondary patient safety screenings for all patients immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
13 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:
14 We recommended that the facility ensure 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:
15 We recommended that the facility ensure appropriate barriers are in place to restrict unauthorized or accidental access to magnetic resonance imaging Zone IV.
Closure Date:
16 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:
17 We recommended that clinicians obtain and document informed consent for tissue plasminogen activator and that facility managers monitor compliance.
Closure Date:
18 We recommended that facility managers post stroke guidelines in all areas where patients may present with stroke symptoms.
Closure Date:
19 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
20 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
21 We recommended that facility managers provide a stroke education program for employees involved in assessing and treating stroke patients and that facility managers monitor compliance.
Closure Date:
22 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:
23 We recommended that Radiology Service revise its policy to clearly define the required on-call reporting time for computed tomography scan and magnetic resonance imaging and the on-call response time for radiology interpretation.
Closure Date:
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| 12-03002-102 | Administrative Investigation, Appearance of a Conflict of Interest, Fayetteville VA Medical Center, Fayetteville, NC | Administrative Investigation | ||
1 We recommend that the Deputy Under Secretary for Health for Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Project Manager.
Closure Date:
2 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against Mr. Hoffman, Ms. Goolsby, Mr. Galkowski, and Ms. Kaplan.
Closure Date:
3 We recommend that the DUSHOM ensure Mr. Hoffman, Ms. Goolsby, Mr. Galkowski, Ms. Kaplan, and the Project Manager take refresher ethics training directly related to the matters described in this report.
Closure Date:
4 We recommend that OGC review this entire matter from start to end, to include but not limited to, the solicitation of interested property owners, the MST evaluation of properties, property ownership and purchase, and the Project Manager being the project manager with oversight of the construction of the leased healthcare center and determine the appropriate corrective action, if any, to take.
Closure Date:
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15039