Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-04378-97 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Hudson Valley Health Care System, Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff protect patient-identifiable information on laboratory specimens during transport from the Carmel CBOC to the parent facility.
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 drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 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:
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.
Closure Date:
7 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
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| 14-04223-100 | Combined Assessment Program Review of the VA North Texas Health Care System, Dallas, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Executive Quality, Safety, and Value Committee continue to meet and ensure that aggregated data is reviewed, that problems or opportunities for improvement are identified, that specific actions are documented, and that actions are fully implemented and monitored over time.
2 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.
3 We recommended that the Critical Care Committee review each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that the committee consistently collect code data.
4 We recommended that the Surgical Work Group meet monthly.
5 We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
6 We recommended that the quality control policy for scanning include 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.
7 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users and that facility managers monitor compliance.
8 We recommended that the facility conduct contrast reaction drills in the magnetic resonance imaging area and that facility managers monitor compliance.
9 We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
10 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.
11 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.
12 We recommended that the facility implement a stroke care designation appropriate to its inpatient acute care complexity.
13 We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
14 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
15 We recommended that facility managers post stroke guidelines in the Emergency Department and on the intensive care and acute inpatient care units.
16 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
17 We recommended that facility managers provide a stroke education program.
18 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.
19 We recommended that facility managers ensure that applicable Nursing Service employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and 12-lead electrocardiogram competency assessment and validation completed and documented.
20 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
21 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of scopes of practice and includes all required elements and that facility managers monitor compliance.
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| 14-04215-99 | Combined Assessment Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners' folders do not contain licensure verification information.
Closure Date:
2 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility appropriately protect computer monitors from public viewing on the medical and surgical units and that facility managers monitor compliance.
Closure Date:
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.
Closure Date:
5 We recommended that the facility designate a committee to oversee consult management.
Closure Date:
6 We recommended that the Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
Closure Date:
7 We recommended that Radiology Service revise the computed tomography scan and magnetic resonance imaging on-call policy to require a 30-minute reporting time.
Closure Date:
8 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the surgical intensive care unit.
Closure Date:
9 We recommended that Domiciliary Care for Homeless Veterans and Post-Traumatic Stress Disorder Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Closure Date:
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| 14-04211-94 | Combined Assessment Program Review of the VA Hudson Valley Health Care System, Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure licensed independent practitioners trained to perform airway management are fully privileged.
Closure Date:
2 We recommended that the facility complete the conversion from the six-part credentialing and privileging folder to the two-part privileging folder.
Closure Date:
3 We recommended that the Emergency Response Committee document review of 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:
4 We recommended that facility managers ensure public restrooms are free of insects and monitor compliance.
Closure Date:
5 We recommended that the facility clean and/or repair dirty/damaged wheelchairs in patient care areas or remove them from service.
Closure Date:
6 We recommended that facility managers ensure walk-off sticky mats are in place at construction site entrances to minimize dust, ensure site entrances are secured, and monitor compliance.
Closure Date:
7 We recommended that the facility not stock heparin in concentrations of more than 5,000 units per milliliter in patient care areas or document approval by the Chief of Pharmacy to stock in these concentrations.
Closure Date:
8 We recommended that the facility revise the plan for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
Closure Date:
10 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:
11 We recommended that the facility revise the stroke policy to address screening for difficulty swallowing and use of the National Institutes of Health Stroke Scale and tracking of its use and that the 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 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:
14 We recommended that the facility comply with Veterans Health Administration directive requirements for exempted facilities, or if the facility plans intubations during emergency responses, they comply with Veterans Health Administration requirements for non-exempted facilities.
Closure Date:
15 We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
Closure Date:
16 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:
17 We recommended that the facility ensure a provider with completed emergency airway management privileges or a clinician with completed emergency airway management scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
18 We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
Closure Date:
19 We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.
Closure Date:
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| 14-05132-90 | Combined Assessment Program Summary Report - Evaluation of Pressure Ulcer Prevention and Management at Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility policy addresses outpatient pressure ulcer prevention and treatment.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish pressure ulcer committees with appropriate professional representation.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities' pressure ulcer programs define requirements for employee training regarding pressure ulcer risk assessment, skin assessment and management, and documentation of skin assessment findings and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians revise pressure ulcer prevention plans when patients' risk levels change and that facility managers monitor compliance.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document patient/caregiver pressure ulcer education and that facility managers monitor compliance.
Closure Date:
6 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document skin inspections and Braden scales daily during hospitalization, including the day of discharge, and that facility managers monitor compliance.
Closure Date:
7 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish processes to monitor consistency in documentation of pressure ulcer stage, location, date acquired, and risk scale score and take appropriate actions to address inconsistencies.
Closure Date:
8 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians document wound care follow-up plans for patients discharged with unhealed pressure ulcers and that the facility provides needed supplies.
Closure Date:
9 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees secure medications stored in patients' rooms.
Closure Date:
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| 14-04219-98 | Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended 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 facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
3 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:
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.
Closure Date:
5 We recommended that the facility create/designate a committee to oversee consult management.
Closure Date:
6 We recommended that the Medicine, Mental Health, Surgical, and Rehabilitation Services' Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
Closure Date:
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.
Closure Date:
8 We recommended that scanned magnetic resonance imaging documents are accurate and complete and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
Closure Date:
10 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:
11 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
12 We recommended that the facility revise the emergency airway management policy to include demonstration of competency by both direct and video laryngoscopy.
Closure Date:
13 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 managers monitor compliance.
Closure Date:
14 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:
15 We recommended that facility managers ensure the Psychosocial Residential Rehabilitation Treatment Program environment is clean and monitor compliance.
Closure Date:
16 We recommended that the facility ensure that Psychosocial Residential Rehabilitation Treatment Program stained ceiling tiles are replaced, damaged baseboards and chipped wall tiles are repaired or replaced, and the emergency exit door is repaired.
Closure Date:
17 We recommended that clinicians document all required vaccination administration elements and that facility managers monitor compliance.
Closure Date:
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| 15-00430-103 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages | National Healthcare Review | ||
1 We recommended that the Interim Under Secretary for Health continue to develop and implement staffing models for critical need occupations.
Closure Date:
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| 14-04221-91 | Combined Assessment Program Review of the Memphis VA Medical Center, Memphis, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinicians consistently complete final peer reviews within required timeframes and obtain written requests for extensions approved by the Facility Director and that facility managers monitor compliance.
Closure Date:
2 We recommended that the Cardiopulmonary Resuscitation Committee fully review each code episode.
Closure Date:
3 We recommended that the Surgical Work Group meet monthly and include the Chief of Staff as a member.
Closure Date:
4 We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
5 We recommended that the quality control policy for scanning include all required elements.
Closure Date:
6 We recommended that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
Closure Date:
7 We recommended that Infection Control Committee meeting minutes reflect implementation of actions to address high-risk areas and provide sufficient follow-up actions to address identified problems.
Closure Date:
8 We recommended that facility managers ensure all designated critical care nurses receive hazardous material training and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure all negative pressure control systems in isolation rooms are functional and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure all crash cart medications are current and daily crash cart inspections are consistently documented and include all required elements and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
12 We recommended that facility managers ensure designated employees receive annual automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
13 We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
14 We recommended that requesters consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
Closure Date:
16 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:
17 We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
Closure Date:
18 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:
19 We recommended that facility managers post stroke guidelines in all areas where patients may present with stroke symptoms.
Closure Date:
20 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
21 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:
22 We recommended that facility managers ensure that nursing staff who perform 12-lead electrocardiograms have a current competency assessment and validation included in their competency checklists and have competency assessment and validation documentation completed.
Closure Date:
23 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists for employees on the post-anesthesia care unit.
Closure Date:
24 We recommended that the facility revise the emergency airway management policy to include all required Veterans Health Administration elements.
Closure Date:
25 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and a written exam and that facility managers monitor compliance.
Closure Date:
26 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:
27 We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
Closure Date:
| ||||
| 14-04218-92 | Combined Assessment Program Review of the St. Cloud VA Health Care System, St. Cloud, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 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:
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| 13-03324-85 | Follow-up Audit of the Information Technology Project Management Accountability System | Audit | ||
1 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish procedures to ensure the Office of Product Development completes all required Planning Reviews (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
2 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure personnel performing Compliance Reviews assess the accuracy and reasonableness of cost information reported on the Project Management Accountability System Dashboard (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
3 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure hiring actions are completed by acquiring the vacant Federal employee positions in the Project Management Accountability System Business Office (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
4 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, not exercise future options of the task order used to augment Project Management Accountability System Business Office staffing once hiring actions have been completed.
Closure Date:
5 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete modification of the Project Management Accountability System Dashboard so that it maintains a complete audit trail of baseline data by including planned, revised, and actual figures for project life-cycle and increment costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
6 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete development and implementation of a sound methodology to capture and report planned and actual total project and increment level costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
7 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure project managers capture and report reliable cost data and maintain adequate audit trails to support how the cost information reported on the Project Management Accountability System Dashboard was derived in the interim until actions to automate budget traceability and shift VA’s IT projects to increment-based contracts are completed (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
8 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, clearly define the term “enhancement of an existing system or its infrastructure” and require Service Delivery and Engineering project teams to track and report costs associated with enhancements on the Project Management Accountability System Dashboard.
Closure Date:
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15039