Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-02383-152 | Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 The VA Desert Pacific Healthcare Network Director strengthens Sterile Processing Service oversight to ensure timely communication of audit findings with action plan expectations to facility leaders.
Closure Date:
2 The VA Desert Pacific Healthcare Network Director ensures entry of audit results into the Sterile Processing Accountability Tool within the required time frame.
Closure Date:
3 The VA Desert Pacific Healthcare Network Director ensures audit results are shared with the Sterile Processing Advisory Board per Veterans Health Administration requirements.
Closure Date:
4 The VA New Mexico Health Care System Director ensures Sterile Processing Service has a process to communicate all instances when high-level disinfection documentation cannot be located to the associated clinical services when the reusable medical devices was used in patient care.
Closure Date:
5 The VA New Mexico Health Care System Director ensures Sterile Processing Service has a formal process in place to sustain daily quality assurance reviews and monitors compliance.
Closure Date:
6 The VA New Mexico Health Care System Director ensures Sterile Processing Service leaders demonstrate clear communication of Sterile Processing Service staff roles and responsibilities in accordance with Veterans Health Administration High Reliability Organization principles and values.
Closure Date:
7 The VA New Mexico Health Care System Director ensures the facility’s Sterile Processing Service identifies and resolves high-level disinfection documentation errors as they occur, prior to use of associated reusable medical devices on patients.
Closure Date:
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| 23-00121-158 | Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures practitioners from other facilities with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for solo licensed independent practitioners.
Closure Date:
2 The Medical Center Director ensures staff conduct environment of care inspections in non-patient care areas at least once per fiscal year.
Closure Date:
3 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00674-153 | Opportunities Exist to Better Integrate Health-Related Social Needs and Social Determinants of Health into Discharge Assessment and Planning | National Healthcare Review | ||
1 The Under Secretary for Health considers the need for a national policy establishing the inclusion of social determinants of health/health-related social needs into discharge assessment and planning.
Closure Date:
2 The Under Secretary for Health considers the implementation of a standardized electronic health record template, such as the Assessing Circumstances and Offering Resources for Needs tool, that includes the assessment of social determinants of health/health-related social needs of hospitalized patients.
Closure Date:
3 The Under Secretary for Health evaluates barriers to assessing social determinants of health/health-related social needs when patients are discharged from VA medical centers.
Closure Date:
4 The Under Secretary for Health promotes the use of health equity tools across VA medical centers
Closure Date:
5 The Under Secretary for Health promotes the establishment of partnerships of VA medical centers with community resources to address social determinants of health/health-related social needs.
Closure Date:
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| 23-00102-150 | Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures staff maintain a safe environment by keeping walls in good repair.
Closure Date:
2 The Associate Director ensures staff check over-the-door alarms in the inpatient mental health unit according to the manufacturer’s guidelines.
Closure Date:
3 The Associate Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
Closure Date:
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| 23-00119-156 | Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.
Closure Date:
3 The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.
Closure Date:
4 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
5 The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.
Closure Date:
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| 23-00104-134 | Comprehensive Healthcare Inspection of the Central Virginia VA Health Care System in Richmond | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations for all Level 3 peer reviews to providers and ensure they implement the improvement actions.
Closure Date:
2 The Chief of Staff ensures the Medical Executive Council documents its review of licensed independent practitioners’ professional practice evaluations and recommend privileges based on the results.
Closure Date:
3 The Executive Director ensures staff store reusable medical equipment in temperature- and humidity-controlled storage locations.
4 The Associate Director ensures staff keep storage rooms and areas used by patients clean and safe.
Closure Date:
5 The Chief of Staff limits medication access to approved staff members.
Closure Date:
6 The Associate Director ensures all toilet rooms within proximity to areas where pelvic examinations are performed, and all women’s, unisex, and family public restrooms have feminine hygiene products available at no cost.
Closure Date:
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| 23-00540-146 | Comprehensive Healthcare Inspection Program and Care in the Community Report: Mammography Services and Breast Cancer Care | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with the National Oncology Program and Veterans Integrated Service Network directors, ensure facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.
Closure Date:
2 The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.
Closure Date:
3 The Under Secretary for Health, Veterans Integrated Service Network directors, and facility leaders ensure staff enter data into the local cancer registry database in a timely manner.
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| 23-00107-135 | Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs incorporate service-specific criteria in professional practice evaluations.
Closure Date:
2 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00098-151 | Comprehensive Healthcare Inspection of the VA Nebraska-Western Iowa Health Care System in Omaha | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
Closure Date:
2 The Chief of Staff ensures service chiefs document Focused Professional Practice Evaluation results in licensed independent practitioners’ profiles.
Closure Date:
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| 23-01602-147 | Increased Utilization of Primary Care in the Community by the VA Loma Linda Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director confirms that a mechanism is in place to monitor primary care patient aligned care team staffing and panel sizes at the non-VHA-operated clinics to ensure staff are available to care for enrolled patients.
Closure Date:
2 The VA Loma Linda Healthcare System Director directs a review be done of VA Loma Linda Healthcare System adherence to Veterans Health Administration metrics for the processing and scheduling of community care consults and, if not met, determines the reasons for noncompliance, creates an action plan to address deficiencies, and monitors for compliance.
Closure Date:
3 The VA Loma Linda Healthcare System Director conducts an assessment of the community- based outpatient clinic steering committee to ensure consistent oversight of quality of care and staffing levels for all of the VA Loma Linda Healthcare System’s VA outpatient clinics.
Closure Date:
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14921