Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-04226-125 | Combined Assessment Program Review of the VA Ann Arbor Healthcare System, Ann Arbor, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that credentialing and privileging folders do not contain information that is not permitted.
2 We recommended that the Surgical Work Group meet monthly and that the Chief of Staff attend meetings.
3 We recommended that the Morbidity and Mortality Conference review all surgical deaths with identified problems or opportunities for improvement.
4 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.
5 We recommended that the facility designate a committee to oversee consult management.
6 We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings date the forms upon review prior to the scan and that facility managers monitor compliance.
7 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.
8 We recommended that the facility revise the stroke policy to address timeliness of completion and interpretation of computed tomography scans, timeframe for the availability of the stroke team, and the difference in approach to patients presenting within the facility’s defined timeframe and those presenting outside the defined timeframe and that the facility managers fully implement the revised policy.
9 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
10 We recommended that clinicians obtain and document signed informed consent and that facility managers monitor compliance.
11 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
12 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
13 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.
14 We recommended that facility managers ensure that critical care unit employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
15 We recommended that the facility revise the emergency airway management policy to include that portable videolaryngoscopes be available at all times for use by clinicians.
16 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.
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| 14-04229-130 | Combined Assessment Program Review of the Beckley VA Medical Center, Beckley, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Chief of Staff consistently attend meetings of the newly established Surgical Work Group.
Closure Date:
2 We recommended that the facility ensure service lines report electronic health record quality data to the Electronic Health Record Committee and that the committee analyze the data at least quarterly.
Closure Date:
3 We recommended that facility managers ensure patient care areas are clean and in good repair and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure restrooms in the Emergency Department are clean and in good repair and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure the nurse call system alarms in the Emergency Department are audible and visual and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
7 We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
Closure Date:
8 We recommended that Level 2 personnel document referral to a radiologist of patients identified as having applicable conditions during secondary screening and that facility managers monitor compliance.
Closure Date:
9 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:
10 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
11 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:
12 We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor compliance.
Closure Date:
13 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:
14 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
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| 14-02689-122 | Inspection of the VA Regional Office Boston, Massachusetts | Review | ||
1 We recommended the Boston VA Regional Office Director implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations for temporary 100 percent disability evaluations.
Closure Date:
2 We recommended the Boston VA Regional Office Director develop and implement a plan to review for accuracy the 189 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
Closure Date:
3 We recommended the Boston VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration’s second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing these claims to identify local training needs.
Closure Date:
4 We recommended the Boston VA Regional Office Director provide refresher training for staff on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
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5 We recommended the Boston VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
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6 We recommended the Boston VA Regional Office Director ensure Systematic Analyses of Operations are completed timely according to the annual schedule and that they contain thorough analyses, use appropriate data, and include recommendations with time frames for implementation.
Closure Date:
7 We recommended the Boston VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 14-04476-116 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Cincinnati VA Medical Center, Cincinnati, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure staff can access the
electronic version of safety data sheets at the Florence CBOC.
2 We recommended that the information technology server closet
at the Florence CBOC is maintained according to information technology safety and
security standards.
3 We recommended that the staff at the Florence CBOC receive
scheduled emergency management training.
4 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.
5 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.
6 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
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| 14-03981-119 | Review of Alleged Mismanagement of Informal Claims Processing at VA Regional Office Oakland, California | Audit | ||
1 We recommended the Oakland VA Regional Office Director complete the review of, and take appropriate action on, the remaining 537 informal claims and provide documentation to certify these actions are complete.
Closure Date:
2 We recommended the Oakland VA Regional Office Director implement a plan to provide training to staff on proper procedures for processing informal claims and assess the effectiveness of that training.
Closure Date:
3 We recommended the Oakland VA Regional Office Director implement a plan to ensure oversight of those staff assigned to process the informal claims.
Closure Date:
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| 14-04386-124 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA North Texas Health Care System, Dallas, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the information technology server closet at the Polk Street VA Annex Clinic is maintained according to information technology safety and security standards.
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 consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 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:
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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| 14-04213-115 | Combined Assessment Program Review of the Tomah VA Medical Center, Tomah, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that the Emergency Services Committee physician member consistently attends meetings and participates in code reviews.
Closure Date:
2 We recommended that the Safe Patient Handling Committee track patient handling injury data.
Closure Date:
3 We recommended that the Medical Record Committee include physician documentation in the review of electronic health record quality.
Closure Date:
4 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 complete review of scanned documents to ensure readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
Closure Date:
5 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
6 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
7 We recommended that facility managers ensure that medications
are secured at all times and monitor compliance.
Closure Date:
8 We recommended that the facility conduct and document annual complete system checks of the community living center's elopement prevention system and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility ensure the high-alert/hazardous medication list is available for staff reference on the acute medicine unit and both community living center units.
Closure Date:
11 We recommended that the facility ensure nursing staff review monthly inspections of nursing station medication areas.
Closure Date:
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| 14-01708-123 | Healthcare Inspection – Staffing and Patient Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that senior leadership and nursing managers fully implement the VHA Nurse Staffing Methodology Plan as required.
Closure Date:
2 We recommended that the Facility Director ensure that senior leadership and nursing managers fully evaluate the medical intensive care and step down units' patient mix, staffing plan, patterns of floating, physical layout, and unit assignments for opportunities for improvement and take necessary action.
Closure Date:
3 We recommended that the Facility Director ensure that patient incident reporting processes be strengthened so that all patient incidents or safety concerns are reported promptly to the patient safety manager.
Closure Date:
4 We recommended that the Facility Director ensure that nursing staff perform and document fall risk assessments as required.
Closure Date:
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| 14-04389-106 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Erie VA Medical Center, Erie, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period.
2 We recommended that managers develop and communicate an egress plan for the safety of all patients.
3 We recommended that processes are strengthened to ensure that women veterans can access gender-specific restrooms without entering public areas.
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
6 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.
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.
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
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| 14-04224-107 | Combined Assessment Program Review of the Erie VA Medical Center, Erie, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers monitor the recently revised reprivileging process to ensure practitioners have the appropriate skills and training for emergency airway management.
Closure Date:
2 We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
Closure Date:
3 We recommended that Medicine Service designate an Automated Data Processing Applications Coordinator.
Closure Date:
4 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
5 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:
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15039