Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02067-253 | Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode.
2 We recommended that the Surgical Work Group continue to meet monthly and document its review of required performance data elements and National Surgical Office reports.
3 We recommended that processes be strengthened to ensure that all surgical deaths with identified problems or opportunities for improvement are reviewed by the Surgical Work Group.
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee representative from Surgical Service consistently attends meetings and that the blood/transfusions usage review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
5 We recommended that processes be strengthened to ensure that Environment of Care Committee minutes reflect discussion of actions taken in response to identified deficiencies and that actions are tracked to closure.
6 We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and that compliance be monitored.
7 We recommended that the facility’s stroke policy be revised to
address data gathering for analysis and improvement and that compliance be
monitored.
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.
9 We recommended that stroke guidelines be posted on the critical care unit and the acute inpatient unit.
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
11 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
12 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.
13 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.
14 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.
15 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.
16 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.
17 We recommended that processes be strengthened to ensure that construction site inspection documentation includes the time of the inspection, the team members present, and the time when corrective actions occurred.
18 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of unsafe conditions identified during inspections and follow-up actions in response to those conditions and that minutes track actions to completion.
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| 14-00924-247 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that the installed modification alarm works consistently so that staff can be notified when veterans require assistance for entry into the Hamlet CBOC.
Closure Date:
2 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 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:
4 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed Fluoroquinolones was administered, prescribed, or modified.
Closure Date:
5 We recommended that staff consistently provide written medication information that includes the Fluoroquinolones.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 14-01293-243 | Combined Assessment Program Review of the VA New York Harbor Healthcare System, New York, New York | 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 the Cardiopulmonary Resuscitation Committee reviews each resuscitation code episode.
3 We recommended that the Surgical Review Group meet monthly and include the Chief of Staff as a member.
4 We recommended that processes be strengthened to ensure that all designated same day surgery and post-anesthesia care unit employees receive bloodborne pathogens training annually and that compliance be monitored.
5 We recommended that the Brooklyn campus eye clinic examination room sinks have foot controls, long-blade handles, or automatic no touch sensors.
6 We recommended that the Manhattan campus eye clinic have glasses/goggles of the appropriate optical density available that are specifically marked for each type of laser and that compliance be monitored.
7 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.
8 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
9 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
10 We recommended that processes be strengthened to ensure that employees involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
11 We recommended that processes be strengthened to ensure that patients presenting with stroke symptoms receive laboratory tests for cardiac markers and that compliance be monitored.
12 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.
13 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 the modifications and that compliance be monitored.
14 We recommended that processes be strengthened to ensure that staff document the reasons for discontinuing or not providing restorative nursing services and that compliance be monitored.
15 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on range of motion and resident transfers.
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.
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| 14-00922-240 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Providence VA Medical Center, Providence, Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Hyannis and Middletown CBOCs’ contract laboratory facilities to the parent facility.
Closure Date:
2 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:
3 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers complete required training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 14-00923-237 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | 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 Milo C. Huempfner CBOC.
2 We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Cleveland CBOC.
3 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
4 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
5 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.
6 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.
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.
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| 14-03010-251 | Healthcare Inspection - Improper Closure of Non-VA Care Consults, Carl Vinson VA Medical Center, Dublin, GA | Hotline Healthcare Inspection | ||
1 We recommended that the VISN Director review the circumstances surrounding the batch closures and confer with appropriate VA offices to determine the need for administrative action, if any.
Closure Date:
2 We recommended that the Facility Director track the timeliness of NVCC appointment scheduling and promptly respond to potential delays in care.
Closure Date:
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| 14-01291-241 | Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group consistently meet monthly.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Medicine Service attends meetings.
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 screen patients for difficulty swallowing prior to oral intake.
Closure Date:
5 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:
6 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to residents' care plans and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff modify restorative nursing interventions as needed and document the modifications and that compliance be monitored.
Closure Date:
8 We recommended that process be strengthened to ensure that hand-off communication occurs between Physical Medicine and Rehabilitation Service and the community living center when residents are discharged from therapy to ensure that restorative nursing services occur.
Closure Date:
9 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training for range of motion.
Closure Date:
10 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 magnetic resonance imaging and that compliance be monitored.
Closure Date:
11 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:
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| 14-00727-239 | Combined Assessment Program Summary Report – Evaluation of Hospice and Palliative Care in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that at least the minimum required Palliative Care Consult Team staffing is provided.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that end-of-life care training is provided to staff who work in areas where they are likely to encounter patients at the end of their lives.
Closure Date:
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| 14-00904-226 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 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:
4 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:
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| 14-01501-229 | Inspection of VA Regional Office Des Moines, Iowa | Review | ||
1 We recommend the Des Moines VA Regional Office Director conduct a review of the 131 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the Des Moines VA Regional Office Director implement a plan for an additional level of review of special monthly compensation claims.
Closure Date:
3 We recommend the Des Moines VA Regional Office Director implement a plan to ensure staff follow the policy for the special operations team to process special monthly compensation decisions.
Closure Date:
4 We recommend the Des Moines VA Regional Office Director develop and implement a plan to ensure staff prioritize processing of benefits reductions at the expiration of due process as required.
Closure Date:
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15039