Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00235-195 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Wilmington VA Medical Center, Wilmington, Delaware | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a panic alarm system is installed at the Cape May County CBOC.
Closure Date:
2 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens.
Closure Date:
3 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Kent County CBOC.
Closure Date:
4 We recommended that the parent facility document Emergency Management Plan-specific training completed for the Cape May County CBOC clinical providers.
Closure Date:
5 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
6 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
7 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:
8 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:
9 We recommended that the facility medication reconciliation policy complies with VHA policy.
Closure Date:
10 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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| 14-00914-190 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Eastern Kansas Health Care System, Topeka, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that external signage clearly identifies the building as a VA CBOC at the Garnett CBOC.
Closure Date:
2 We recommended that fire drills are performed every 12 months at the Garnett CBOC.
Closure Date:
3 We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Garnett CBOC.
Closure Date:
4 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Garnett CBOC.
Closure Date:
5 We recommended that the information technology server closets at the Chanute and Fort Scott CBOCs are maintained according to information technology safety and security standards.
Closure Date:
6 We recommended that managers conduct environment of care rounds semi-annually at the Garnett CBOC.
Closure Date:
7 We recommended that the parent facility include staff at the Chanute, Fort Scott, and Garnett CBOCs in required education, training, planning, and participation in annual disaster exercises.
Closure Date:
8 We recommended that the parent facility’s Emergency Management Committee evaluate the Chanute, Fort Scott, and Garnett CBOCs’ emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
Closure Date:
9 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
10 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:
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| 14-00911-193 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the information technology server closet at the Grants Pass CBOC is maintained according to information technology safety and security standards.
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.
3 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
4 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.
5 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.
6 We recommended that staff document the evaluation of patients’ level of understanding for the medication education.
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| 14-00912-192 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at South Texas Veterans Health Care System, San Antonio, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that external signage clearly identifies the building as a VA CBOC at the Beeville CBOC.
Closure Date:
2 We recommended that managers maintain clean carpets at the Frank M. Tejeda Satellite CBOC.
Closure Date:
3 We recommended that all identified environment of care deficiencies at the Beeville and San Antonio Primary Care Network CBOCs are reported to and tracked by the parent facility's Environment of Care Committee until resolution.
Closure Date:
4 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:
5 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:
6 We recommended that staff document the evaluation of patient's level of understanding for the flouroquinolone medication education.
Closure Date:
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| 13-02665-197 | Healthcare Inspection - Medication Management Issues in a High Risk Patient, Tuscaloosa VAMC, Tuscaloosa, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that providers comply with local policies related to opioid therapy in patients with chronic pain.
Closure Date:
2 We recommended that the Facility Director ensure that all patients who are prescribed methadone are educated about potential adverse effects and warned about interactions with other over-the-counter, prescribed, and/or illicit drugs.
Closure Date:
3 We recommended that the Facility Director develop a system to ensure communication and coordination of care, particularly for patients who receive routine and ongoing care from multiple providers.
Closure Date:
4 We recommended that the Facility Director ensure that Suicide Prevention staff follow policies regarding communication and coordination of care for patients on the High Risk for Suicide list.
Closure Date:
5 We recommended that the Facility Director ensure that clinical reviews and root cause analyses comply with Veterans Health Administration and local policies.
Closure Date:
6 We recommended that the Facility Director evaluate the care of the patient summarized in this report and confer with Regional Counsel regarding the need for possible disclosure.
Closure Date:
7 We recommended that the Facility Director ensure access to interdisciplinary pain management care for chronic pain patients who do not respond to standard medical treatment.
Closure Date:
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| 14-00383-171 | Inspection of VA Regional Office New York, NY | Review | ||
1 We recommend the New York VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommend the New York VA Regional Office Director develop and implement a plan to review for accuracy the 320 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
3 We recommend the New York VA Regional Office Director develop and implement a plan to ensure staff comply with VBA and local second-signature requirements for traumatic brain injury claims
Closure Date:
4 We recommend that the New York VA Regional Office Director implement a plan to ensure staff comply with VARO policy requiring evaluation of higher-level special monthly compensation claims by staff assigned to the Special Operations team.
Closure Date:
5 We recommend the New York 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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| 13-03604-198 | Healthcare Inspection - Quality of Care and Staffing Concerns, Salem VA Medical Center, Salem, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director continue to monitor and address increases in post-operative infection rates and take appropriate corrective actions when indicated.
Closure Date:
2 We recommended that the Facility Director evaluate the admission process from the emergency department and monitor inter-unit transfer patterns, and take corrective actions as indicated.
Closure Date:
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| 12-03869-187 | Healthcare Inspection – Follow-Up of Mental Health Inpatient Unit and Outpatient Contract Programs, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that a standardized and facility-wide repository be developed and implemented to monitor patients referred to community service boards.
Closure Date:
2 We recommended that the Facility Director strengthen processes to ensure that patients are tracked for follow-up beyond the first contracted mental health care appointment.
Closure Date:
3 We recommended that the Facility Director strengthen communication between the facility and the community service boards to better integrate and coordinate medical and mental health aspects of patient care.
Closure Date:
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| 14-00905-182 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Huntington VA Medical Center, Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Prestonsburg 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 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:
5 We recommended that staff consistently provide written medication information as required.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
VA OIG
Closure Date:
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| 14-01785-184 | Combined Assessment Program Summary Report – Evaluation of the Controlled Substances Inspection Program at 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 leaders, ensures that pharmacy physical security surveys are conducted and identified deficiencies are corrected and that compliance is monitored.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that quarterly controlled substances inspection trend reports of identified discrepancies, problematic trends, and potential areas for improvement are completed and provided to facility Directors.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that monthly inspections of all non-pharmacy controlled substances areas are conducted and that compliance is monitored.
Closure Date:
4 We recommended that the Under Secretary for Health ensures that VHA defines in policy acceptable reasons for missed controlled substances area inspections and provides guidance regarding Controlled Substances Coordinator performance of monthly inspections.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate 2 transfers of controlled substances from one storage area to another area, reconcile 1 day’s dispensing from the pharmacy to each automated unit, and verify electronic or written orders for 5 randomly selected dispensing activities.
Closure Date:
6 We recommended that the Under Secretary for Health, in
conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors perform quarterly physical counts of the emergency drug cache and monthly verifications of seals and that compliance is monitored.
Closure Date:
7 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate completion of all required drug destruction activities.
Closure Date:
8 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate accountability for all prescription pads stored in the pharmacy.
Closure Date:
9 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors conducting outpatient pharmacy inspections verify written prescriptions for 10 percent of (or a maximum of 50) schedule II drugs dispensed.
Closure Date:
10 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors receive annual training regarding problematic issues identified through external surveys and other quality control measures.
Closure Date:
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15039