Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02073-57 | Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
Closure Date:
2 We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
Closure Date:
3 We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly and review relevant data elements.
Closure Date:
5 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Transfusion Review Committee members from Medicine, Surgery, and Anesthesia Services consistently attend meetings.
Closure Date:
7 We recommended that the facility¿s stroke policy/plan/guideline be revised to address screening for difficulty swallowing, that the policy/plan/guideline be fully implemented, and that compliance be monitored.
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 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:
10 We recommended that processes be strengthened to ensure that fire emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
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 that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure 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 compliance be monitored.
Closure Date:
14 We recommended that barriers are properly used to restrict access to magnetic resonance imaging Zone III and that compliance be monitored.
Closure Date:
15 We recommended that magnetic resonance imaging technologists have visual contact at all times with patients in the magnet room.
Closure Date:
16 We recommended that processes be strengthened to ensure that the two-way communication device is regularly tested and that compliance be monitored.
Closure Date:
17 We recommended that a Magnetic Resonance Imaging Safety Committee be appointed.
Closure Date:
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| 14-04368-56 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Samuel S. Stratton VA Medical Center, Albany, New York | 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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| 14-02887-64 | Healthcare Inspection – Quality of Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that patient safety incidents and concerns are reported promptly to the patient safety manager and that the need for further review and/or corrective actions is assessed initially by the patient safety manager.
Closure Date:
2 We recommended that the Facility Director ensure that cardiac resuscitation events in the operating room are appropriately documented and reviewed.
Closure Date:
3 We recommended that the Facility Director ensure that the Critical Incident Tracking Notification system recipient list includes the patient safety manager.
Closure Date:
4 We recommended that the Facility Director assess staffing in the Quality Management Service and take appropriate actions to meet the workload requirements.
Closure Date:
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| 14-00517-54 | Review of Alleged Mismanagement at VHA’s Massachusetts Veterans Epidemiology Research and Information Center | Audit | ||
1 We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, improve oversight controls to ensure Massachusetts Veterans Epidemiology Research and Information Center staff protects all veteran personal information in accordance with VA policy.
Closure Date:
2 We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, ensure that portable storage devices used by the Massachusetts Veterans Epidemiology Research and Information Center are encrypted.
Closure Date:
3 We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, ensure VA Boston Healthcare System Information Security Officers have full access to all VA Boston Healthcare System office space, including all Massachusetts Veterans Epidemiology Research and Information Center office space, in order to perform their oversight responsibilities.
Closure Date:
4 We recommended the Director of Veterans Integrated Service Network 1 develop an oversight and monitoring plan to ensure Massachusetts Veterans Epidemiology Research and Information Center staff comply with VA’s information security requirements.
Closure Date:
5 We recommended the Director of Veterans Integrated Service Network 1 implement a plan to maximize use of the off-site commercial space if continued need for the office space is justified.
Closure Date:
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| 13-00872-52 | Healthcare Inspection – Follow-Up Evaluation of Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn, VA Medical Center, Columbia, SC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that patient information, medical and surgical supplies, medications, grafts, and patches are stored properly throughout the facility and that compliance be monitored to ensure sustained improvement.
Closure Date:
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| 14-04705-62 | Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet | National Healthcare Review | ||
1 We recommended that the Interim Under Secretary for Health conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review.
Closure Date:
2 We recommended that the Interim Under Secretary for Health ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care.
Closure Date:
3 We recommended that after reviewing the circumstances of any inappropriate resolution of consults, the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
Closure Date:
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| 14-00351-53 | Healthcare Inspection – Alleged Inappropriate Opioid Prescribing Practices, Chillicothe VA Medical Center, Chillicothe, OH | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director identify patients receiving recurrent prescriptions for high potency and/or large quantity opioid medications and ensure appropriate periodic assessments.
Closure Date:
2 We recommended that the Facility Director ensure that prescribing physicians check the Ohio Automated Rx Reporting System for patients who are prescribed high potency and/or large quantity opioid medications.
Closure Date:
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| 14-00930-14 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Central Alabama Veterans Health Care System, Montgomery, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Dothan and Wiregrass CBOCs.
Closure Date:
2 We recommended that managers ensure that material safety data sheets are readily available to staff at the Wiregrass CBOC.
Closure Date:
3 We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Dothan CBOC.
Closure Date:
4 We recommended that processes are improved to ensure the tracking of chemical inventories at the Dothan CBOC.
Closure Date:
5 We recommended that the effectiveness of the panic alarm system is evaluated at the Wiregrass CBOC.
Closure Date:
6 We recommended that panic alarms are tested and testing is documented at the Dothan and Wiregrass CBOCs.
Closure Date:
7 We recommended that no clean items are stored in the medical (infectious) waste storage room at the Wiregrass CBOC.
Closure Date:
8 We recommended that signage is installed to identify the medical (infectious) waste storage room at the Wiregrass CBOC.
Closure Date:
9 We recommended that computer screens are secured to eliminate viewing of personally identifiable information by unauthorized individuals at the Wiregrass CBOC.
Closure Date:
10 We recommended that processes are improved to ensure the use of privacy screens on computers in high-traffic areas at the Wiregrass CBOC.
Closure Date:
11 We recommended that the parent facility maintain evidence of the contractor’s compliance with facility required education, training, planning, and participation in annual disaster exercises for the Dothan and Wiregrass CBOCs.
Closure Date:
12 We recommended that the parent facility’s Emergency Management Committee evaluate the Dothan and Wiregrass CBOCs’ emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
Closure Date:
13 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
14 We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
15 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:
16 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
17 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
18 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
19 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 13-01859-42 | Audit of VHA's National Call Center for Homeless Veterans | Audit | ||
1 We recommended the Interim Under Secretary for Health end the use of the answering machine and improve the utilization and accessibility of the National Call Center for Homeless Veterans current counselors before consideration is given to hiring additional staff.
Closure Date:
2 We recommended the Interim Under Secretary for Health implement effective performance measures and benchmarks for the National Call Center for Homeless Veterans and performance standards for staff to ensure the accessibility of counselors, the efficient management of calls, and the proper referral of veterans' calls.
Closure Date:
3 We recommended the Interim Under Secretary for Health routinely monitor and analyze National Call Center for Homeless Veterans telephone system data to assess the quality of Call Center support services, including the counselors' accessibility, efficiency in answering calls, and issuance of referrals.
Closure Date:
4 We recommended the Interim Under Secretary for Health ensure that Call Center officials adhere to Veterans Health Administration's National Call Center for Homeless Veterans policy requirements related to monitoring referred calls.
Closure Date:
5 We recommended the Interim Under Secretary for Health implement management controls to ensure VA medical facilities receive feedback on the quality of their referral responses and on needed corrections and improvements to the homeless support services extended to referred veterans.
Closure Date:
6 We recommended the Interim Under Secretary for Health review the results of this audit with the VA medical facilities' homeless points of contact to ensure they understand their responsibility to ensure referred veterans receive needed support services.
Closure Date:
7 We recommended the Interim Under Secretary for Health implement controls to ensure National Call Center for Homeless Veterans special purpose funds are used as intended.
Closure Date:
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| 14-05128-51 | An Analysis of Mental Health, Primary Care, and Specialty Care Productivity and Related Issues, El Paso VA Health Care System, El Paso, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director review clinic productivity and implement a plan to enhance productivity in those clinics for which productivity is an issue.
Closure Date:
2 We recommended the Facility Director ensure clinical departments accurately capture provider workload.
Closure Date:
3 We recommended the Facility Director direct clinical departments to review labor mapping to ensure the labor mapping is up to date and accurately reflects the percentage of provider time allocated to direct patient care.
Closure Date:
4 We recommended the Facility Director review the quadrants into which mental health, primary care, and specialty care clinics appear on the VHA Specialty Productivity-Access Report and Quadrant (SPARQ) tool, and evaluate and address underlying factors.
Closure Date:
5 We recommended the Facility Director take measures to promote alignment of organizational structure with clinic centered accountability, goals, and expectations.
Closure Date:
6 We recommended the Facility Director revise policy and/or processes to facilitate primary care Patient Aligned Care Team (PACT) operation and support PACT model workflow and clinic-wide coordination of care.
Closure Date:
7 We recommended the Facility Director identify specialties particularly vulnerable to loss of a provider and explore contingency plans to potentially mitigate the impact of provider loss on clinic disruption.
Closure Date:
8 We recommended the Facility Director take measures to promote non-provider to provider communication within mental health, primary care, and specialty clinics.
Closure Date:
9 We recommended the Facility Director consider inter-service agreements between primary care and specialty care clinics.
Closure Date:
10 We recommended the Facility Director direct MH clinic leadership to evaluate access and patient engagement for specific types of outpatient mental health services, including individual psychotherapy and intensive substance use treatment, in order to provide a more encompassing picture of MH access.
Closure Date:
11 We recommended the Facility Director provide a quarterly update on facility efforts to revise outpatient MH clinic processes to promote greater continuity of care through the regular outpatient MH clinic and to better focus the walk-in clinic toward serving those in need of walk-in care.
Closure Date:
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15039