Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-04451-88 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Illiana Health Care System, Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers maintain a clean and functioning environment of care at the Peoria CBOC.
Closure Date:
2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Peoria CBOC.
Closure Date:
3 We recommended that the information technology server closet at the Peoria CBOC is maintained according to information technology safety and security standards.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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| 14-04382-86 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of St. Cloud VA Health Care System, St. Cloud, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months at the Brainerd CBOC.
Closure Date:
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| 14-04214-70 | Combined Assessment Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
Closure Date:
2 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
Closure Date:
3 We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
Closure Date:
4 We recommended that facility managers consult with the manufacturer regarding the issue of dirty-appearing sinks and take any recommended actions.
Closure Date:
5 We recommended that facility managers ensure all designated employees receive annual bloodborne pathogens training and monitor compliance.
Closure Date:
6 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:
7 We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
8 We recommended that requestors consistently include “inpatient” in the consult title 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 clinicians provide printed stroke education to patients upon discharge 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 revise the emergency airway management policy to include the availability of videolaryngoscopes for use by clinicians and a plan for managing a difficult airway.
Closure Date:
15 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
Closure Date:
16 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:
17 We recommended that the facility complete at least two preventive ethics improvement cycles each fiscal year.
Closure Date:
18 We recommended that the facility consistently schedule follow-up appointments within the timeframes requested by providers.
Closure Date:
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| 14-02082-82 | Combined Assessment Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility establish a Surgical Work Group that meets monthly, includes all required members, and documents oversight of surgical performance improvement activities such as morbidity and mortality reviews.
Closure Date:
2 We recommended that that processes be strengthened to ensure that soiled utility rooms are secured at all times and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that public restrooms on the Department of Housing and Urban Development and VA Supportive Housing floor are clean and well maintained and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that auditory privacy is maintained in all interview areas on the Department of Housing and Urban Development and VA Supportive Housing floor and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that sterile supplies for same day surgery/the post-anesthesia care unit are stored in a secured room where appropriate temperature and humidity levels can be maintained and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
9 We recommended that stroke guidelines be posted on the critical care unit, in the emergency department, and on all inpatient units.
Closure Date:
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
11 We recommended that the facility collect and report to VHA 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 processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and documented in the electronic health record and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that medications in resident rooms are secured.
Closure Date:
14 We recommended that processes be strengthened to ensure that all domiciliary admission denials contain documentation regarding the reason for the denial and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
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| 14-04385-65 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Tomah VA Medical Center, Tomah, Wisconsin | 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 Wausau CBOC.
Closure Date:
2 We recommended that hand hygiene compliance is monitored at the Wausau CBOC and reported to the Infection Control Committee.
Closure Date:
3 We recommended that privacy is provided for veterans in the examination rooms at the Wausau CBOC.
Closure Date:
4 We recommended that the information technology server closet at the Wausau CBOC is maintained according to information technology safety and security standards.
Closure Date:
5 We recommended that the staff at the Wausau CBOC receive regular information and updates on their responsibilities in emergency response operations.
Closure Date:
6 We recommended that the staff at the Wausau CBOC participate in scheduled emergency management training and exercises.
Closure Date:
7 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
8 We recommended that RN Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
9 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:
10 We recommended that clinic staff ensures that written patient educational materials provided to patients prior to or at the time of consent for HIV testing include all required elements.
Closure Date:
| ||||
| 14-04383-78 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Memphis VA Medical Center, Memphis, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Savannah, TN, CBOC
receive the required training on hazardous materials.
2 We recommended that managers ensure that safety inspections
are performed on all the medical equipment at the Savannah, TN, CBOC in accordance with VA and Joint Commission standards.
3 We recommended that hand hygiene compliance be monitored
at the Savannah, TN, CBOC and reported to the Infection Control Committee.
4 We recommended that signage is installed at the Savannah, TN,
CBOC to clearly identify all exits.
5 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Savannah, TN, CBOC and that compliance is monitored.
6 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Savannah, TN, CBOC to the parent facility.
7 We recommended that examination tables and curtains provide adequate privacy for women veterans at the Savannah, TN, CBOC.
8 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Savannah, TN, CBOC.
9 We recommended that access to the information technology server closet at the Savannah, TN, CBOC is restricted and maintained according to information technology safety and security standards.
10 We recommended that access to the information technology server closet at the Savannah, TN, CBOC is documented consistently according to information technology safety and security standards.
11 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
12 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.
13 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.
14 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
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| 14-04210-63 | Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Medical Executive Committee and the Facility Director consistently review and approve revised privilege forms.
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 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 performance data.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly.
Closure Date:
5 We recommended that the facility share patient handling injury data.
Closure Date:
6 We recommended that facility managers ensure patient care area floors and public restrooms are clean and monitor compliance.
Closure Date:
7 We recommended that the facility repair damaged floors and wall surfaces in patient care areas.
Closure Date:
8 We recommended that the facility repair damaged wheelchairs and furnishings in patient care areas or remove them from service.
Closure Date:
9 We recommended that facility managers ensure all required members of the Environment of Care Committee consistently attend meetings and monitor compliance.
Closure Date:
10 We recommended that the facility use special medication labeling and/or institute unique storage practices for the complete list of look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure monthly medication storage area inspections are consistently completed and monitor compliance.
Closure Date:
12 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:
13 We recommended that the facility revise the local policy on inspection of medication storage areas to be consistent with Veterans Integrated Service Network policy.
Closure Date:
14 We recommended that major bed services have designated Automated Data Processing Applications Coordinators.
Closure Date:
15 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:
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 facility managers post stroke guidelines on the three inpatient units and in the two community living centers.
Closure Date:
18 We recommended that clinicians screen patients for difficulty swallowing, that screening be done prior to oral intake, and that facility managers monitor compliance.
Closure Date:
19 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
20 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:
21 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:
22 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and that facility managers monitor compliance.
Closure Date:
23 We recommended that the facility ensure 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:
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| 14-00615-61 | Healthcare Inspection – Alleged Quality of Care and Courtesy Issues at the Alamosa Community Based Outpatient Clinic, Alamosa, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement the CBOC triage guidelines and train staff on the guidelines.
Closure Date:
2 We recommended that the Facility Director ensure that managers appropriately address CBOC staff who exhibit lapses in competency, when identified.
Closure Date:
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| 14-04380-79 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Mobile Outpatient Clinic CBOC receive the required training on hazardous materials.
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 Registered Nurse Care Managers receive motivational interviewing within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that licensed Providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that the Facility Director identifies a Lead Human Immunodeficiency Virus Clinician to carry out required responsibilities.
Closure Date:
6 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:
7 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
8 We recommended that clinic staff ensures that written patient educational materials are provided to patients prior to or at the time of consent for human immunodeficiency virus testing and include all required elements.
Closure Date:
9 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
10 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
| ||||
| 14-02412-69 | Healthcare Inspection – Ophthalmology Service Concerns, VA Illiana Health Care System, Danville, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement all recommendations for interpersonal training for the staff and providers in the Ophthalmology and Optometry Services.
Closure Date:
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15039