Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-01290-222 | Combined Assessment Program Review of the South Texas Veterans Health Care System, San Antonio, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
Closure Date:
2 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that damaged doors and floors and rusted lockers in patient care areas are repaired and that ongoing maintenance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service.
Closure Date:
5 We recommended that processes be strengthened to ensure that physicians complete and document discharge progress notes or patient discharge instructions and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinicians complete and document the National Institutes of Health Stroke Scale for each stroke patient and that compliance be monitored.
Closure Date:
7 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:
8 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.
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9 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:
10 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.
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11 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff document the reasons for not providing restorative nursing services when those services are care planned and that compliance be monitored.
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13 We recommended that processes be strengthened to ensure that the restorative registered nurse or designee signs and provides feedback, if indicated, on restorative aide notes.
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14 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
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15 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.
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16 We recommended that processes be strengthened to ensure that secondary patient safety screenings are reviewed by Level 2 magnetic resonance imaging personnel on the same day as the magnetic resonance imaging and that compliance be monitored.
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17 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.
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18 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:
19 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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| 14-00916-218 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that external signage clearly identifies the building as a VA CBOC at the Fort Stockton CBOC.
Closure Date:
2 We recommended that managers maintain a clean and functioning environment of care at the Hobbs CBOC.
Closure Date:
3 We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
4 We recommended that managers ensure staff can access the electronic version of the chemical inventory at the Abilene and San Angelo CBOCs.
Closure Date:
5 We recommended that processes are improved to ensure the tracking of chemical inventories at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
6 We recommended that the effectiveness of the panic alarm system is evaluated at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
7 We recommended that a separate room is provided to store medical (infectious) waste at the Hobbs CBOC.
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8 We recommended that fire drills are performed every 12 months at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
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9 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Abilene and San Angelo CBOCs to the parent facility.
Closure Date:
10 We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Fort Stockton CBOC.
Closure Date:
11 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Fort Stockton CBOC.
Closure Date:
12 We recommended that the information technology server closets at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs are maintained according to information technology safety and security standards.
Closure Date:
13 We recommended that the parent facility document Emergency Management Preparedness-specific training completed by the West Texas VA Health Care System CBOC clinical providers.
Closure Date:
14 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
15 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.
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16 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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17 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.
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18 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
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19 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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20 We recommended that staff provide medication counseling/education as required.
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21 We recommended that staff document the evaluation of patient's level of understanding for the medication education.
Closure Date:
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| 14-00931-213 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at John D. Dingell VA Medical Center, Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to PACT.
Closure Date:
2 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:
3 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 14-01322-215 | Healthcare Inspection – Quality of Care and Staff Safety Concerns at the Huntsville Community Based Outpatient Clinic, Huntsville, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensures that documentation of treatment with opioid medications meets Veterans Health Administration requirements.
Closure Date:
2 We recommended that the Facility Director ensures that staff consistently document responses to abnormal test results.
Closure Date:
3 We recommended that the Facility Director ensures that patients are notified of test results within the defined timeframe and that notification is documented in accordance with Veterans Health Administration requirements.
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4 We recommended that the Facility Director ensures that staff adhere to the facility policy for the management of non-VA medical records.
Closure Date:
5 We recommended that the Facility Director ensures that Community Based Outpatient Clinic provider privileges are in accordance with Veterans Health Administration requirements.
Closure Date:
6 We recommended that the Facility Director ensures the mental health standard operating procedure is updated to incorporate all procedures available for management of a mental health emergency at the Community Based Outpatient Clinic.
Closure Date:
7 We recommended that the Facility Director ensures that Community Based Outpatient Clinic panic alarms are functional.
Closure Date:
8 We recommended that the Facility Director ensures that a pain management policy is implemented.
Closure Date:
9 We recommended that the Facility Director ensures that the quality of entries in the electronic health record is reviewed at least quarterly.
Closure Date:
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| 13-03899-216 | Administrative Investigation, Prohibited Personnel Practice and Preferential Treatment, National Cemetery Administration, VA Central Office | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff confer with OHR and OGC to determine the appropriate corrective action to take, if any, as it relates to the two applicants listed on the certificate of eligibles who were not afforded the same preference in this hiring effort.
Closure Date:
2 We recommend that the VA Chief of Staff confer with OGC to review any active contracts with Ms. Noonan to ensure there is no organizational conflict of interest, as well as determine the appropriateness of the sole-source one-to-one contracts, and take the appropriate corrective action, if any.
Closure Date:
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| 14-00918-204 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Grand Junction VA Medical Center, Grand Junction, Colorado | Comprehensive Healthcare Inspection Program | ||
1 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:
2 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:
3 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
4 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Closure Date:
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| 14-02396-212 | Healthcare Inspection – Alleged Medication Cart Deficiencies and Unsafe Medication Administration Practices, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that an adequate number of fully functioning medication carts are available for nurses to administer medications safely and on time.
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2 We recommended that the Facility Director ensure that nurses document the reasons for late medication administration.
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3 We recommended that the Veterans Integrated Service Network Director enhance processes to improve purchasing and contracting efficiency for patient care equipment and items.
Closure Date:
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| 13-02892-217 | Healthcare Inspection – Alleged Mismanagement in the Cardiac Catheterization Laboratory, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that nurse staffing is appropriate for the volume and types of procedures performed in the cardiac catheterization laboratory and that the requisite nurse competencies are maintained.
2 We recommended that the System Director ensure that the policies and procedures regarding the rapid response team, code blue team, and Anesthesia Services are updated as needed to reflect desired practices for managing cardiac catheterization laboratory emergencies.
3 We recommended that the System Director ensure that the staff receive training on updated policies and procedures regarding the rapid response, code blue team and Anesthesia Services.
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| 13-03468-203 | Audit of NCA's Rural Veterans Burial Initiative | Audit | ||
1 We recommended the Under Secretary for Memorial Affairs establish a methodology to identify the number and percentage of served and unserved rural veterans throughout the Nation.
Closure Date:
2 We recommended the Under Secretary for Memorial Affairs publish a national map showing the areas and number of served and unserved rural veterans.
Closure Date:
3 We recommended the Under Secretary for Memorial Affairs establish performance goals for the percentage of rural and urban veterans served.
Closure Date:
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| 13-03699-209 | Review of VBA’s Special Initiative To Process Rating Claims Pending Over 2 Years | Audit | ||
1 We recommended the Under Secretary for Benefits implement a plan toidentify all provisionally-rated claims and ensure the proper controls areentered in the electronic system to track, manage, and complete them.
Closure Date:
2 We recommended the Under Secretary for Benefits implement actions toinclude provisionally-rated claims in the rating inventory and correct theaging of provisional claims in pending workload statistics.
Closure Date:
3 We recommended the Under Secretary for Benefits implement a plan toexpedite final decisions on all issues in provisionally-rated claims.
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4 We recommend the Under Secretary for Benefits implement actions to complete quality reviews to ensure accuracy of all provisionally rated claims processed under this special initiative.
Closure Date:
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15039