Recommendations
2145
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00071-158 | Combined Assessment Program Review of the West Palm Beach VA Medical Center, West Palm Beach, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that emergency airway management privileges granted are appropriate for the practitioners' skills and training.
Closure Date:
2 We recommended that the Cardiopulmonary Resuscitation Committee review 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:
3 We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document did not meet image quality controls and a correction process if scanned items have errors.
Closure Date:
4 We recommended that Environment of Care Committee minutes include consistent discussion of rounds deficiencies, trends, and actions and tracking of actions to closure.
Closure Date:
5 We recommended that infection prevention and control meeting minutes consistently reflect discussion of identified high-risk priority areas.
Closure Date:
6 We recommended that facility managers ensure patient care areas and public restrooms are clean and toilet paper dispensers are in good repair and monitor compliance.
Closure Date:
7 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility secure medication carts when not in use and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
10 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
12 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility update the local consult policy for policy changes and review the policy at least every 3 years and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility conduct contrast reaction and fire emergency drills in magnetic resonance imaging and that the facility managers monitor compliance.
Closure Date:
15 We recommended that the facility conduct initial patient safety screenings and that the facility managers monitor compliance.
Closure Date:
16 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 the facility managers monitor compliance.
Closure Date:
17 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:
18 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
19 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:
20 We recommended that facility managers ensure that all nursing employees who perform 12-lead electrocardiograms have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
21 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the 2B-ICU.
Closure Date:
22 We recommended that the facility revise the emergency airway management policy to include a specific plan to manage difficult airways.
Closure Date:
23 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements, including a written test, and that facility managers monitor compliance.
Closure Date:
24 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:
25 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:
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| 14-03927-197 | Healthcare Inspection – Patient Telemetry Monitoring Concerns, Michael E. DeBakey VA Medical Center, Houston, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the appropriateness of assigning patients to telemetry is reviewed.
Closure Date:
2 We recommended that the Facility Director ensure dedicated wireless telephones are continuously carried by unit charge nurses or designees for effective communication between unit and telemetry monitoring technicians as required by local policy.
Closure Date:
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| 15-00108-194 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Martinsburg VA Medical Center, Martinsburg, West Virginia | 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 Fort Detrick CBOC.
Closure Date:
2 We recommended that employees at the Fort Detrick CBOC receive the required training on hazardous materials.
Closure Date:
3 We recommended that personal protective equipment is available for all staff at the Fort Detrick CBOC.
Closure Date:
4 We recommended that staff protect patient-identifiable information on laboratory specimens at the Fort Detrick CBOC.
Closure Date:
5 We recommended that the information technology server closet at the Fort Detrick CBOC is maintained according to information technology safety and security standards.
Closure Date:
6 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within the time frame specified in VHA policy.
Closure Date:
8 We recommended that all providers and clinical associates in the outpatient clinics receive health coaching training within the time frame specified in VHA policy.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-02139-156 | Healthcare Inspection – Suicide Risk and Alleged Medical Management Issues, Hampton VA Medical Center, Hampton, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that contracted providers in all patient care areas complete the Veterans Health Administration’s suicide risk management training.
2 We recommended that the Facility Director ensure development of a process to measure the effectiveness of Veterans Health Administration required suicide risk management training for all staff members who have completed it and to provide remedial training when needed.
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| 15-01809-163 | Combined Assessment Program - Evaluation of Coordination of Care in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians provide and document discharge instructions for all identified needs and that facility managers monitor compliance.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reassess patients¿ learning needs prior to providing important instructions, including discharge instructions, and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reconcile conflicting needs and instructions before discharging patients and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that patients receive ordered post-discharge referrals and that facility managers monitor compliance.
Closure Date:
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| 14-02383-175 | Audit of VA's Drug-Free Workplace Program | Audit | ||
1 We recommended the Deputy Assistant Secretary for Human Resources Management ensure that all final selectees for Testing Designated Positions complete pre-employment drug testing prior to appointment.
Closure Date:
2 We recommended the Deputy Assistant Secretary for Human Resources Management collect data that would ensure accountability that all employees selected for random drug testing are tested.
Closure Date:
3 We recommended the Deputy Assistant Secretary for Human Resources Management develop procedures to ensure the Drug Testing coding of employees in Testing Designated Positions is accurate and complete in the Personnel and Accounting Integrated Data system.
Closure Date:
4 We recommended the Deputy Assistant Secretary for Human Resources Management coordinate with the Under Secretary for Health to implement procedures to ensure Custody and Control forms are accurately completed.
Closure Date:
5 We recommended the Deputy Assistant Secretary for Human Resources Management implement processes to adequately monitor local compliance with VA's Drug-Free Workplace Program requirements.
Closure Date:
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| 15-00116-191 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Lima CBOC.
Closure Date:
2 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Lima CBOC and that compliance is monitored.
Closure Date:
3 We recommended that processes are strengthened at the Lima CBOC to ensure that women veterans can access gender-specific restrooms without entering public areas at the Lima CBOC.
Closure Date:
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
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.
Closure Date:
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-04623-120 | Inspection of VA Regional Office Manchester, New Hampshire | Review | ||
1 We recommended the Manchester VA Regional Office Director conduct a review of the 111 temporary 100 percent disability evaluations remaining from their inspection universe as of August 21, 2014, and take appropriate action.
Closure Date:
2 We recommended the Manchester VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations.
Closure Date:
3 We recommended the Manchester VA Regional Office Director enforce Veterans Benefits Administration's second-signature review policy for traumatic brain injury rating decisions.
Closure Date:
4 We recommended the Manchester VA Regional Office Director enforce the VARO's second signature review policy for special monthly compensation and ancillary benefits rating decisions.
Closure Date:
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| 14-04622-150 | Inspection of VA Regional Office Fargo, North Dakota | Review | ||
1 We recommended the Fargo VA Regional Office Director provide training and assess the effectiveness of that training, to ensure staff properly establish permanent disability evaluations when required.
Closure Date:
2 We recommended the Fargo VA Regional Office Director conduct a review of the 40 temporary 100 percent disability evaluations remaining from their universe as of August 21, 2014, and take appropriate action.
Closure Date:
3 We recommended the Fargo VA Regional Office Director implement a plan to ensure staff address all pending issues related to SMC and ancillary benefits.
Closure Date:
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| 15-00880-157 | Review of Alleged Data Manipulation at VA Regional Office Honolulu, HI | Audit | ||
1 We recommended the Honolulu VA Regional Office Director take immediate action to fully review and correct, as appropriate, all improper actions taken by the supervisor.
Closure Date:
2 We recommended the Honolulu VA Regional Office Director ensure staff receive training on the proper procedures for processing dependency questionnaires.
Closure Date:
3 We recommended the Honolulu VA Regional Office Director confer with Regional Counsel and human resources to determine the appropriate administrative action to take, if any, against this employee.
Closure Date:
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15427