Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02081-41 | Combined Assessment Program Review of the VA Northern California Health Care System, Mather, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
Closure Date:
2 We recommended that the Surgical Work Group meet monthly, include the Chief of Staff as a standing member, and document its review of National Surgical Office reports.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed at least quarterly.
Closure Date:
4 We recommended that the Medical Records Committee meet quarterly.
Closure Date:
5 We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Function Team meeting minutes document those actions.
Closure Date:
6 We recommended that processes be strengthened to ensure that rolling equipment and patient weight scales are cleaned on a routine basis and that damaged furniture in patient care areas is repaired or removed from service.
Closure Date:
7 We recommended that the eye clinic waiting room carpet be replaced to avoid tripping hazards.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
Closure Date:
9 We recommended that the facility's stroke policy be revised to address screening patients for difficulty swallowing and the difference in approach to patients presenting within and after 2 hours of onset of symptoms, that the policy be fully implemented, and that compliance be monitored.
Closure Date:
10 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:
11 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
12 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Closure Date:
14 We recommended that the facility collect and report to the Provision of Care Committee 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:
15 We recommended that processes be strengthened to ensure that clinicians obtain a partial thromboplastin time test while assessing patients presenting with stroke symptoms and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
Closure Date:
17 We recommend that that processes be strengthened to ensure that initial patient safety screenings are conducted and documented in the electronic health records and that compliance be monitored.
Closure Date:
18 We recommend 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:
19 We recommended that facility policy be revised to fully meet VHA requirements and that processes be strengthened to ensure that quarterly Magnetic Resonance Imaging Safety Committee meetings are held and biannual magnetic resonance imaging safety inspections are conducted and that compliance be monitored.
Closure Date:
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| 14-02080-29 | Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that staff document monthly restorative nursing services progress notes in residents’ electronic health records and that compliance be monitored.
2 We recommended that processes be strengthened to ensure that residents are offered transfer from their wheelchairs to regular dining chairs during meal periods.
3 We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health record.
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| 14-02079-10 | Combined Assessment Program Review of the Central Alabama Veterans Health Care System, Montgomery, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Critical Care Committee reviews 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 code data is collected.
Closure Date:
2 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
Closure Date:
3 We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee representatives from Surgery and Anesthesia Services consistently attend meetings.
Closure Date:
5 We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Prevention Committee minutes document those actions, reflect follow-up on actions implemented to address identified problems, and consistently reflect analysis of surveillance activities.
Closure Date:
6 We recommended that processes be strengthened to ensure that fluoroquinolone dosages and/or medications ordered at discharge are consistent with the discharge instructions and the pharmacy updates provided to the patient/caregiver and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the electronic health records and that compliance be monitored.
Closure Date:
8 We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
Closure Date:
9 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:
10 We recommended that stroke guidelines be posted on the intensive care unit and the acute medical/surgical unit and that the facility provide a stroke educational program for employees.
Closure Date:
11 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that care plans are updated when community living center residents’ restorative care needs change and that all residents are reassessed for restorative nursing needs at the intervals required by local policy.
Closure Date:
14 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify restorative nursing interventions as needed, and document those modifications and that compliance be monitored.
Closure Date:
15 We recommended that the Minimum Data Set Coordinator collaborate with the Restorative Nurse to communicate pertinent minimum data set and quality indicator data to restorative nursing program staff.
Closure Date:
16 We recommended that the facility establish written procedures for handling emergencies in magnetic resonance imaging and that compliance be monitored.
Closure Date:
17 We recommended that processes be strengthened to ensure that contrast reaction drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that secondary patient safety screening forms are scanned into the patients’ electronic health records and that compliance be monitored.
Closure Date:
20 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:
21 We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that patients with positive colorectal cancer screening test results receive diagnostic testing within the required timeframe and that compliance be monitored.
Closure Date:
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| 14-02078-38 | Combined Assessment Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Quality Management Board meet at least quarterly.
Closure Date:
2 We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Executive Committee of the Medical Staff.
Closure Date:
3 We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are initiated.
Closure Date:
4 We recommended that the Executive Committee of the Medical Staff discuss and document its approval of the use of another facility's providers for teledermatology services.
Closure Date:
5 We recommended that processes be strengthened to ensure that all specialty clinic employees receive annual bloodborne pathogens training.
Closure Date:
6 We recommended that eye clinic exam/procedure room sinks have foot controls, long-blade handles, or automatic no touch sensors.
Closure Date:
7 We recommended that processes be strengthened to ensure that the medical information from non-VA hospitalizations is consistently scanned into the electronic health record and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians document acknowledgement of their patients¿ recent non-VA hospitalizations.
Closure Date:
9 We recommended that processes be strengthened to ensure that all patients are notified of abnormal Pap smear results/values within the expected timeframe and that notification is documented in the electronic health record and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that all patients are notified of normal lab results/values and radiology results within the expected timeframe and that notification is documented in the electronic health record.
Closure Date:
11 We recommended that processes be strengthened to ensure that patients and/or their families receive a copy of the safety plan and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that all employees receive Level 1 training and that the training be documented in employee training records.
Closure Date:
13 We recommended that processes be strengthened to ensure that residential rehabilitation unit employees perform and document daily inspections for unsecured medications and that compliance be monitored.
Closure Date:
14 We recommended that a process be in place to alert residential rehabilitation unit employees when alarmed doors that are not considered main points of entry are opened from the inside and that the process be tested regularly.
Closure Date:
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| 14-00661-43 | Healthcare Inspection – Radiology Scheduling and Other Administrative Issues, VA Loma Linda Healthcare System, Loma Linda, California | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director strengthen processes to ensure that patients are involved in the scheduling process, that program managers periodically monitor exam cancelations, and that staff accurately document patient dispositions and actions taken related to patient scheduling.
Closure Date:
2 We recommended that the Facility Director ensure that clinicians review the electronic health records of the two patients who had unfulfilled computed tomography orders to determine whether follow-up actions are needed.
Closure Date:
3 We recommended that the Facility Director monitor compliance with the facility's newly implemented scheduling policy.
Closure Date:
4 We recommended that the Facility Director ensure that proper equipment and software is available for uploading non-VA images and that staff are trained.
Closure Date:
5 We recommended that the Facility Director ensure that program managers periodically assess and monitor the appropriateness of early walk-in ultrasound clinic closure and take necessary steps to ensure outpatients receive timely studies.
Closure Date:
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| 13-01545-11 | Review of Alleged Mismanagement of VA's Office of Public and Intergovernmental Affairs Outreach Contracts | Audit | ||
1 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs limit future use of time and materials contracts to those instances where the extent or duration of the work cannot be anticipated with any reasonable degree of confidence.
2 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that significant new contract requirements are solicited in lieu of merely modifying existing contracts to meet new needs.
3 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that contractor billings are approved based on sufficient documentation to demonstrate that contractors are meeting performance-based requirements.
4 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs implement improved oversight of contractor activities to ensure they are appropriate to meet contract terms and do not include inherently Governmental functions.
5 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs develop and implement program performance metrics to determine whether outreach and awareness campaigns are improving veterans’ awareness of and access to VA services and benefits.
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| 12-02576-30 | Audit of VHA's Support Service Contracts | Audit | ||
1 We recommended the Interim Under Secretary for Health implement a quality assurance program that provides sufficient oversight to ensure that contracting issues are corrected by the responsible contracting office.
Closure Date:
2 We recommended the Interim Under Secretary for Health implement a mechanism to facilitate and ensure contracting officers’ performance can be objectively evaluated against their performance standards.
Closure Date:
3 We recommended the Interim Under Secretary for Health monitor contracting officer performance deficiencies and ensure training is provided to correct identified deficiencies.
Closure Date:
4 We recommended the Interim Under Secretary for Health ensure contracting staff complete Integrated Oversight Process reviews in accordance with established policies and contracting officers’ performance standards.
Closure Date:
5 We recommended the Interim Under Secretary for Health revise Integrated Oversight Process review procedures to include a review to ensure Advisory and Assistance services are identified and approved.
Closure Date:
6 We recommended the Interim Under Secretary for Health ensure that contracting officers delegate in writing contracting officers’ representatives requirements and authorities to monitor contracts, as required by Federal and VA acquisition policy and contracting officers’ performance standards.
Closure Date:
7 We recommended the Interim Under Secretary for Health ensure that contracting officers conduct and document quarterly meetings with contracting officers’ representatives as required by VA acquisition policy.
Closure Date:
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| 14-02083-24 | Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that providers complete and document patient discharge progress notes or discharge instructions and that compliance be monitored.
Closure Date:
3 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:
4 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
Closure Date:
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| 14-02101-09 | Inspection of VA Regional Office Huntington, West Virginia | Review | ||
1 The Huntington VA Regional Office Director develop and implement a plan to review for accuracy the 138 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
2 The Huntington VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on identifying and returning insufficient medical examination reports related to traumatic brain injury claims to medical facilities for correction.
3 The Huntington 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.
4 The Huntington VA regional Office Director develops and implements a plan to ensure staff complies with local second-signature requirements for processing special monthly compensation.
5 The Huntington VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
6 The Huntington VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans
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| 14-01519-40 | Healthcare Inspection – Quality and Coordination of Care Concerns at Three Veterans Integrated Service Network 11 Facilities | Hotline Healthcare Inspection | ||
1 We recommended that the Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible institutional disclosure.
Closure Date:
2 We recommended that the Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
Closure Date:
3 We recommended the Network Director conduct a thorough review of the Northern Indiana Health Care System Mental Health Service’s processes and leadership.
Closure Date:
4 We recommended that the Network Director ensure providers’ electronic health record documentation is consistent with VHA Handbook 1907.01, Health Information Management and Health Records, especially in regards to discharge instructions and summaries, patient problem lists, and critical telephone and fax communications, as discussed in this report.
Closure Date:
5 We recommended that the Network Director ensure that Northern Indiana Health Care System Non-VA Care Coordination staff case manage patients consistent with their current functional statements or that the role of Non-VA Care Coordination staff be reassessed and functional statements changed to reflect tasks actually performed by the Non-VA Care Coordination staff.
Closure Date:
6 We recommended that the Network Director ensure that all Northern Indiana Health Care System providers receive ongoing professional practice evaluations consistent with VHA Directive 1100.19, Credentialing and Privileging.
Closure Date:
7 We recommended that the Network Director ensure that responsible clinical staff review the patient’s electronic health record and initiate appropriate follow-up action consistent with VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, when a patient is a “no show.”
Closure Date:
8 We recommended that the Network Director ensure that the Northern Indiana Health Care System Director develop guidelines for documenting and responding to secure messages.
Closure Date:
9 We recommended that the Network Director ensure that Northern Indiana Health Care System mental health patients be assigned a Mental Health Treatment Coordinator and that a process is in place to reassign coordinators in the event of staff departure consistent with the Deputy Undersecretary for Health for Operations and Management’s “Assignment of the Mental Health Treatment Coordinator” and local policy requirements.
Closure Date:
10 We recommended that the Network Director ensure that Northern Indiana Health Care System Community Based Outpatient Clinic mental health services are provided consistent with VHA Directive 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.
Closure Date:
11 We recommended that the Network Director ensure processes are in place at the Northern Indiana Health Care System to ensure continuity of mental health care in the event of staff departure and/or reassignment.
Closure Date:
12 We recommended that the Network Director ensure Northern Indiana Health Care System telephone triage, suicide prevention program, and emergency department staff receive training regarding expected psychiatric emergency response.
Closure Date:
13 We recommended that the Network Director ensure Northern Indiana Health Care System providers implement stepped consultative care and integrate behavioral health with the primary care of chronic pain consistent with VHA Directive 2009-053, Pain Management.
Closure Date:
14 We recommended that the Network Director ensure that Richard L. Roudebush VA Medical Center Clinical Application Coordinators remove Computerized Patient Record System consult order templates from facility ordering systems when a consult service is no longer offered.
Closure Date:
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15039