Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-01253-208 | Inspection of VA Regional Office Columbia, South Carolina | Review | ||
1 We recommended the Columbia VA Regional Office Director develop and implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommended the Columbia VA Regional Office Director conduct a review of the 658 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommended the Columbia VA Regional Office Director ensure staff receive training on the proper processing of traumatic brain injury claims and implement a plan to assess the effectiveness of that training.
Closure Date:
4 We recommended the Columbia VA Regional Office Director ensure staff receive training on the proper processing of special monthly compensation and ancillary benefit claims and implement a plan to assess the effectiveness of that training.
Closure Date:
5 We recommend the Columbia VA Regional Office Director ensure that staff receive training on VBA policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
Closure Date:
6 We recommended the Columbia VA Regional Office Director develop and implement a plan to ensure prompt action on benefits reduction cases.
Closure Date:
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| 14-00902-207 | Inspection of VA Regional Office Atlanta, Georgia | Review | ||
1 We recommended the Atlanta VA Regional Office Director develop and implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommended the Atlanta VA Regional Office Director develop and implement a plan to review for accuracy the 776 temporary 100 percent disability evaluations remaining from our inspection universe.
Closure Date:
3 We recommended the Atlanta VA Regional Office Director provide refresher training for staff on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
Closure Date:
4 We recommended the Atlanta 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.
Closure Date:
5 We recommended the Atlanta 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.
Closure Date:
6 We recommended the Atlanta VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
Closure Date:
7 We recommended the Atlanta VA Regional Office Director promote staff awareness of the second-signature review policy for processing special monthly compensation and ancillary benefits and ensure that qualified staff conduct the secondary reviews.
Closure Date:
8 We recommended the Atlanta VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Closure Date:
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| 14-01289-227 | Combined Assessment Program Review of the James J. Peters VA Medical Center, Bronx, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
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 Cardiopulmonary Resuscitation Committee 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 processes be strengthened to ensure that electronic health record data is analyzed and reported at least quarterly in Electronic Health Record Committee meeting minutes.
Closure Date:
5 We recommended that the facility implement a quality control policy for scanning.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee includes a member from Medicine Service, that the member from Surgery Service consistently attends meetings, and that the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
7 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in the Cardiopulmonary Resuscitation, Operative and Other Procedures, Peer Review, and Environment of Care Committees.
Closure Date:
8 We recommended that processes be strengthened to ensure that glucometers are cleaned between patients, damaged glucometer cases are replaced, and optical examination equipment is cleaned routinely and that compliance be monitored.
Closure Date:
9 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 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 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:
14 We recommended that the facility establish written procedures for handling emergencies in magnetic resonance imaging and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that cardiac and contrast reaction emergency drills are conducted in 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 additional Level 2 magnetic resonance imaging personnel be designated, that processes be strengthened to ensure that all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training, and that compliance with training be monitored.
Closure Date:
18 We recommended that appropriate screening be in place to restrict access to magnetic resonance imaging Zones III and IV.
Closure Date:
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| 14-00934-221 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA New York Harbor Healthcare System, New York, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Harlem CBOC to the parent facility.
Closure Date:
2 We recommended that the information technology server closet at the Harlem CBOC is maintained according to information technology safety and security standards.
Closure Date:
3 We recommended that CBOC/PCC 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:
5 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
Closure Date:
7 We recommended that the chief of staff consistently ensure that all Designated Women's Health Providers are designated with the women's health indicator in the Primary Care Management Module.
Closure Date:
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| 14-02065-230 | Combined Assessment Program Review of the Washington DC VA Medical Center, Washington, DC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Chief of Staff reconsider Peer Review Committee membership to ensure that sufficient experienced senior physicians are regular members.
Closure Date:
2 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:
3 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:
4 We recommended that a local observation bed policy be implemented and that data about observation bed use be collected and analyzed.
Closure Date:
5 We recommended that processes be strengthened to ensure that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
6 We recommended that the Surgical Work Group meet monthly.
Closure Date:
7 We recommended that processes be strengthened to ensure that electronic health record quality data is analyzed at least quarterly and that the review of electronic health record quality includes most services.
Closure Date:
8 We recommended that the quality control policy for scanning be revised to include the handling of external source documents.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Transfusion Committee members from Medicine and Anesthesia Services consistently attend meetings.
Closure Date:
10 We recommended that processes be strengthened to ensure that Environment of Care Committee and Executive Committee of the Governing Body minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
Closure Date:
11 We recommended that processes be strengthened to ensure that public restrooms are clean and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that the surveillance monitoring system on the locked mental health unit is on at all times and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that the electronic patient monitoring system on the Community Living Center West unit is inspected and checks documented and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that all medications in the emergency department, on the dialysis unit, on the post-anesthesia care unit, and in the eye clinic are secured and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that the medication list provided to the patient/caregiver at discharge is reconciled with the dosage and frequency ordered and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that progress notes in the electronic health record are individualized and accurate.
Closure Date:
17 We recommended that processes be strengthened to ensure that contrast reaction and fire emergency 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 screenings are completed prior to magnetic resonance imaging and documented in the electronic health record 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 the 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 all staff who may need to enter the magnetic resonance imaging area be designated as Level 1 ancillary staff.
Closure Date:
22 We recommended that processes be strengthened to ensure that all designated Level 1 and Level 2 staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
23 We recommended that appropriate physical barriers be in place to restrict access to magnetic resonance imaging Zones III and IV.
Closure Date:
| ||||
| 14-00919-228 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at New Mexico VA Health Care System, Albuquerque, New Mexico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that patients’ personally identifiable information is protected and secured at the Truth or Consequences CBOC.
2 We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
3 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.
4 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
5 We recommended that staff provide medication counseling/education as required.
6 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
7 We recommended that clinical executive/primary care leaders ensure that CBOC/Primary Care Clinic Designated Women’s He
8 We recommended that the chief of staff consistently ensure that all Designated Women’s Health Providers are designated with the women’s health indicator in the Primary Care Management Module.
| ||||
| 14-02063-231 | Combined Assessment Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently initiated.
Closure Date:
2 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
4 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in outlier data, bar codes that were unable to scan, and blood transfusions.
Closure Date:
5 We recommended that processes be strengthened to ensure that nurse call system alarms are functional and that compliance be monitored.
Closure Date:
6 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:
7 We recommended that stroke guidelines be posted in the emergency department, on the critical care units, and on the medical and surgical units.
Closure Date:
8 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:
9 We recommended that processes be strengthened to ensure that staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Closure Date:
| ||||
| 14-00921-223 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Washington DC VA Medical Center, Washington, DC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that external signage is installed that clearly identifies the building as a VA CBOC at the Southern Prince George's County CBOC.
Closure Date:
2 We recommended that managers ensure all interior signs clearly identify the route to and location of the Southern Prince George's County CBOC.
Closure Date:
3 We recommended that the clinic entrance door access is Americans with Disabilities Act accessible at the Southern Prince George's County CBOC.
Closure Date:
4 We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Southern Prince George's County CBOC.
Closure Date:
5 We recommended that signage is installed at the Southern Prince George's County CBOC to clearly identify the location of all fire extinguishers.
Closure Date:
6 We recommended that signage is installed at the Southern Prince George's County CBOC to clearly identify emergency exits from any direction.
Closure Date:
7 We recommended that the information technology server closet at the Southern Prince George's County CBOC is secured according to information technology safety and security standards.
Closure Date:
8 We recommended that the CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training and health-coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
| ||||
| 14-01294-224 | Combined Assessment Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Clinical Executive Council document its discussion of Peer Review Committee quarterly summary reports, including unusual findings or patterns.
Closure Date:
2 We recommended that a local observation bed policy that includes all required elements be implemented.
Closure Date:
3 We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
Closure Date:
4 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
5 We recommended that the Surgical Staff Committee meet monthly, include the Chief of Staff as a member, and document its review of National Surgery Office reports.
Closure Date:
6 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed and data analyzed at least quarterly and that the review of electronic health record quality
Closure Date:
7 We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
Closure Date:
8 We recommended that processes be strengthened to ensure that infection prevention educational materials are available for eye clinic patients, visitors, and family members.
Closure Date:
9 We recommended that processes be strengthened to ensure that employees reprocess ophthalmology lenses and pachymetry probes in accordance with manufacturers¿ instructions and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 8 hours of admission and that compliance be monitored.
Closure Date:
11 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:
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 all acute inpatient units.
Closure Date:
14 We recommended that the facility collect and report to the 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:
15 We recommended that processes be strengthened to ensure that contrast reaction drills are conducted in the magnetic resonance imaging mobile unit at the Hot Springs division and that compliance be monitored.
Closure Date:
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.
Closure Date:
| ||||
| 14-01497-188 | Inspection of VA Regional Office St. Louis, Missouri | Review | ||
1 We recommended the St. Louis VA Regional Office Director develop and implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommended the St. Louis VA Regional Office Director develop and implement a plan to review for accuracy the 559 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
Closure Date:
3 We recommended the St. Louis VA Regional Office Director implement a plan to ensure compliance with local policy requiring staff assigned to a specialized team process traumatic brain injury and special monthly compensation claims.
Closure Date:
4 We recommended the St. Louis VA Regional Office Director clarify local policy by clearly defining which special monthly compensation claims require processing by a specialized team.
Closure Date:
5 We recommended the St. Louis VA Regional Office Director implement a plan to ensure staff comply with local policy requiring Decision Review Officers to conduct second-signature reviews of special monthly compensation claims.
Closure Date:
6 We recommended the St. Louis VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Closure Date:
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15039