Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-03221-08 | Inspection of VA Regional Office Providence, Rhode Island | Review | ||
1 We recommended the Providence VA Regional Office Director conduct a review of the 70 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommended the Providence VA Regional Office Director provide oversight to ensure staff follows Veterans Benefits Administration guidance related to processing reminder notifications for medical reexaminations.
Closure Date:
3 We recommended the Providence VA Regional Office Director ensure staff receive refresher training on proper evaluation of traumatic brain injury and special monthly compensation and ancillary benefits claims and implement plans to ensure the effectiveness of that training.
Closure Date:
4 We recommended the Providence VA Regional Office Director develop and implement a plan to ensure timely completion of Systematic Analyses of Operations.
Closure Date:
5 We recommended the Providence VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff takes timely action on claims requiring rating decisions for reduction of benefits.
Closure Date:
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| 14-00937-31 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern California Health Care System, Mather, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are improved to ensure compliance with requirements for hazardous materials, including tracking of hazardous materials inventories at the Martinez CBOC, reviewing these inventories twice within a 12-month period at the Martinez and Redding CBOCs, and training Martinez CBOC staff to ensure access to the electronic version of the material safety data sheets.
Closure Date:
2 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Fairfield and Martinez CBOCs to the parent facility or contracted processing facility, by securing patient data in the Health Education Room, and through the use of privacy screens on computer monitors at the Martinez Primary Care check-in desk.
Closure Date:
3 We recommended that the parent facility’s Emergency Management Committee includes the CBOC in required education, training, planning, and participation leading up to the annual disaster exercise and evaluates the Fairfield, Martinez, and Redding CBOCs’ emergency preparedness activities and participation in annual disaster exercises.
Closure Date:
4 We recommended that CBOC/Primary Care 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:
5 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 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:
7 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:
8 We recommended that staff provide and document medication counseling/education as required.
Closure Date:
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| 14-02084-16 | Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that completed actions from peer reviews are consistently documented in Peer Review Committee meeting minutes.
Closure Date:
2 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:
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.
Closure Date:
5 We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Blood Utilization Committee representative from Anesthesia Service consistently attends meetings.
Closure Date:
7 We recommended that processes be strengthened to ensure that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
Closure Date:
8 We recommended that processes be strengthened to ensure that the negative pressure control systems in the dialysis isolation rooms are functional and that the dialysis unit water treatment, sterile supply, clean utility, and soiled utility room doors are secured at all times and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that equipment is not stored in the restraint room on the locked mental health unit and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that documentation of pachymetry probe reprocessing in the eye clinic is in accordance with the manufacturer’s instructions and that compliance be monitored.
Closure Date:
11 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:
12 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans, document resident progress towards restorative nursing goals, and document reasons why care planned restorative nursing services were not provided or were discontinued and that compliance be monitored.
Closure Date:
14 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 potential contraindications prior to the scan and that compliance be monitored.
Closure Date:
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| 14-02577-07 | Inspection of VA Regional Office Buffalo, New York | Review | ||
1 We recommended the Buffalo VA Regional Office Director develop and implement a plan to review the 206 temporary 100 percent disability evaluation claims remaining from our inspection universe and take appropriate actions.
Closure Date:
2 We recommended the Buffalo VA Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level Special Monthly Compensation and Ancillary Benefits.
Closure Date:
3 We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure Systematic Analysis of Operations contain thorough analyses, use appropriate data, and include all recommendations needed, along with time frames for implementation.
Closure Date:
4 We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 14-00939-27 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Pembroke Pines CBOC location is clearly identified from the street as a VHA CBOC.
Closure Date:
2 We recommended that the main entrance and restroom doors at the Key Largo CBOC are accessible per Americans with Disabilities Act guidelines.
Closure Date:
3 We recommended that signage is installed at the Pembroke Pines CBOC to clearly identify the location of fire extinguishers.
Closure Date:
4 We recommended that exit signs are visible from all directions at the Key Largo CBOC.
Closure Date:
5 We recommended that personally identifiable information is protected by securing laboratory specimens during transport from the Key Largo and Pembroke Pines CBOCs to the parent facility.
Closure Date:
6 We recommended that clinic staff provide adequate privacy for women veterans at the Key Largo and Pembroke Pines CBOCs.
Closure Date:
7 We recommended that access to the information technology server closet at the Key Largo CBOC is documented.
Closure Date:
8 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
9 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
10 We recommended that staff consistently document and provide written medication information that includes the fluoroquinolones.
Closure Date:
11 We recommended that staff consistently document and provide medication counseling/education as required.
Closure Date:
12 We recommended that staff consistently document the evaluation of patient's level of understanding for the medication education.
Closure Date:
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| 13-02527-23 | Healthcare Inspection – Alleged Nursing Deficiencies Led to Patient's Death, Hampton VA Medical Center, Hampton, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director conduct and document a review to evaluate patient rounds and documentation policies.
Closure Date:
2 We recommended that the Facility Director educate and train all staff regarding patient rounds policies.
Closure Date:
3 We recommended that the Facility Director consult with Regional Counsel regarding institutional disclosure to the patient’s next-of-kin in accordance with VHA Handbook 1004.08.
Closure Date:
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| 14-02076-13 | Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
Closure Date:
2 We recommended that the local observation bed policy be revised to include how the responsible provider is determined and that each observation patient must have a focused goal for the period of observation.
Closure Date:
3 We recommended that processes be strengthened to ensure 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 the Surgical Work Group meet monthly, consistently include the Chief of Staff and operating room manager as members, and document its review of National Surgical Office reports.
Closure Date:
5 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:
6 We recommended that the quality control policy for scanning include the handling of external source documents.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Transfusion Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings and that the blood/transfusions usage review process consistently includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
Closure Date:
8 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that post-anesthesia care unit employees do not consume beverages in treatment areas and that compliance be monitored.
Closure Date:
11 We recommended that the facility's stroke policy be revised to address data gathering for analysis and improvement, that the policy be fully implemented, and that compliance be monitored.
Closure Date:
12 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:
13 We recommended that stroke guidelines be posted on the intensive care unit, on the medical/surgical unit, and in the community living center.
Closure Date:
14 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
15 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:
16 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:
17 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents' care plans and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that staff document the reasons for discontinuing or not providing restorative nursing services when those services are care planned and that compliance be monitored.
Closure Date:
20 We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Closure Date:
21 We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
22 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:
23 We recommended that processes be strengthened to ensure that secondary patient safety screening forms are signed by the patient, family member, or caregiver and that compliance be monitored.
Closure Date:
24 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:
25 We recommended that processes be strengthened to ensure that all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
| ||||
| 14-02074-06 | Combined Assessment Program Review of the Huntington VA Medical Center, Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Quality, Safety, and Value Council meet monthly.
Closure Date:
2 We recommended that processes be strengthened to ensure that results of Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently reported to the Medical Staff Council.
Closure Date:
3 We recommended that the Medical Staff Council discuss and document its approval of the use of another facility's providers for teledermatology services.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee collects code data.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Transfusion Review Committee members from Medicine and Anesthesia Services consistently attend meetings.
Closure Date:
6 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
Closure Date:
7 We recommended that processes be strengthened to ensure that all food service employees use hairnets and gloves when serving food.
Closure Date:
8 We recommended that all privacy curtains in same day surgery and on the post-anesthesia care unit have open mesh tops that extend 18 inches for sprinkler coverage.
Closure Date:
9 We recommended that same day surgery have designated rooms for the storage of dirty instruments, equipment, and housekeeping supplies and that these rooms and the soiled utility room on the post-anesthesia care unit be secured.
Closure Date:
10 We recommended that processes be strengthened to ensure that designated eye clinic employees receive eye laser safety training annually and that compliance be monitored.
Closure Date:
11 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 is monitored.
Closure Date:
12 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:
13 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:
14 We recommended that stroke guidelines be posted in the emergency department, on the intensive care unit, and on the acute inpatient units.
Closure Date:
15 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:
16 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:
17 We recommended that processed be strengthened to ensure that all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
| ||||
| 14-02077-01 | Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
2 We recommended that processes be strengthened to ensure that results of Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently reported to the Medical Executive Board.
3 We recommended that processes be strengthened to ensure that Cardiopulmonary Resuscitation Review Committee code reviews include screening for clinical issues prior to the event that may have contributed to the occurrence of the code.
4 We recommended that the Surgical Quality Work Group meet monthly.
5 We recommended that processes be strengthened to ensure that all surgical deaths with identified problems or opportunities for improvement are reviewed by the Morbidity and Mortality Committee.
6 We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
7 We recommended that processes be strengthened to ensure that Environment of Care Board minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
8 We recommended that processes be strengthened to ensure that the surveillance monitoring systems on the locked mental health units at the York campus are functional and that regular inspections are documented.
9 We recommended that processes be strengthened to ensure that chemicals stored on the dialysis unit at the Nashville campus are secured at all times and that compliance be monitored.
10 We recommended that processes be strengthened to ensure that the negative pressure control systems in the post-anesthesia care unit isolation rooms at both campuses are functional and that compliance be monitored.
11 We recommended that a laser warning sign be posted on the door in the eye clinic laser room at the York campus and that compliance be monitored.
12 We recommended that processes be strengthened to ensure that providers complete and document patient discharge instructions and that compliance be monitored.
13 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
14 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.
15 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.
16 We recommended that stroke guidelines be posted on the intensive care and inpatient medical units.
17 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
18 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
19 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.
20 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.
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| 14-02070-305 | Combined Assessment Program Review of the Alexandria VA Health Care System, Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Inpatient Management Committee reviews each code episode and that code data is collected.
Closure Date:
2 We recommended that the Surgical Review Committee document its review of National Surgical Office reports and monitoring of surgery performance improvement activities.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Blood Usage, Surgical, and Other Invasive Procedures Review Committee members from Medicine, Surgery, and Anesthesia Services consistently attend meetings.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas are clean and in good repair and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that public restrooms are clean and in good repair and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all designated same day surgery and eye clinic employees receive laser safety training in accordance with facility policy and that compliance be monitored.
Closure Date:
7 We recommended that the facility¿s stroke policy be revised to address the difference in approach to patients presenting with symptoms within the facility's defined timeframe to be eligible for tissue plasminogen activator and those presenting outside the defined timeframe 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 processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake and that compliance be monitored.
Closure Date:
10 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:
11 We recommended that the facility collect and report to VHA and the Executive Committee of the Medical Staff 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 the facility offer restorative nursing services and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
Closure Date:
15 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:
16 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:
17 We recommended that the facility designate Level 1 ancillary staff, that processes be strengthened to ensure that Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training, and that compliance with training be monitored.
Closure Date:
18 We recommended that appropriate signage be in place to identify magnetic resonance imaging Zones III and IV.
Closure Date:
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