Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00242-160 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
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 Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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.
Closure Date:
4 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
5 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 14-00231-158 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Aleda E. Lutz VA Medical Center, Saginaw, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the sink faucet control in the handicap
accessible restroom at the Alpena CBOC meets Americans with Disabilities Act Guidelines and is accessible during regular clinic hours.
2 We recommended that processes are improved to ensure review
of the hazardous materials inventory occurs twice within a 12-month period at the Alpena and Bad Axe CBOCs.
3 We recommended processes are strengthened to ensure women
veterans can access gender-specific restrooms without entering public areas at the Bad Axe CBOC.
4 We recommended that the parent facility includes staff at the Alpena and Bad Axe CBOCs in required education, training, planning, and participation in annual disaster exercise.
5 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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| 14-00244-147 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Canandaigua VA Medical Center, Canandaigua, New York | 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 Rochester CBOC.
Closure Date:
2 We recommended that all identified EOC deficiencies at the Rochester CBOC are tracked by the parent facility EOC Committee until resolution.
Closure Date:
3 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
4 We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screens and drinking levels above NIAAA limits.
Closure Date:
5 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
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| 13-00991-154 | Review of Alleged Unauthorized Commitments Within VA | Audit | ||
1 We recommended the Executive in Charge, Office of Management and Chief Financial Officer, review FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.
Closure Date:
2 We recommended the Executive in Charge, Office of Management and Chief Financial Officer, establish policies and procedures to perform recurring reviews of purchase card transactions above the micro-purchase threshold to identify transactions made by cardholders without appropriate warrant authority.
Closure Date:
3 We recommended the Executive in Charge, Office of Management and Chief Financial Officer, revise policies and procedures to verify that purchase card spending limits do not exceed warrant authority limits before issuing individuals purchase cards with spending limits above the micro-purchase threshold.
Closure Date:
4 We recommended the Executive in Charge, Office of Management and Chief Financial Officer, require recurring unauthorized commitment training for purchase cardholders and their approving officials.
Closure Date:
5 We recommended the Executive in Charge, Office of Management and Chief Financial Officer, ensure the Management Quality Assurance Service follow-up on the status of ratification of identified unauthorized commitments.
Closure Date:
6 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, direct Heads of Contracting Activities to perform individual ratification actions for unauthorized commitments identified by the Executive in Charge, Office of Management and Chief Financial Officer’s review of FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold.
Closure Date:
7 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, create and maintain an accurate database of warranted VA contracting officers that includes warrant effective and expiration dates, and specific warrant authority limitations.
Closure Date:
8 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, establish policies and procedures requiring Heads of Contracting Activities to complete ratification actions within a specified time period after the identification of unauthorized commitments.
Closure Date:
9 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, limit institutional ratifications by ensuring every unauthorized commitment meets the ratification review requirements.
Closure Date:
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| 13-04243-151 | Combined Assessment Program Review of the Wilmington VA Medical Center, Wilmington, Delaware | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility establish a policy for scanning health records and that compliance with the newly established policy be monitored.
Closure Date:
2 We recommended that the dialysis patient care area have an emergency eyewash station.
Closure Date:
3 We recommended that processes be strengthened to ensure that the dialysis unit's chemical storage room is locked when unattended and that compliance be monitored.
Closure Date:
4 We recommended that the clinical laboratory urinalysis section ceiling leak be repaired and that ceiling tiles in the clinical laboratory urinalysis section and blood bank and in the ambulatory surgery medication room be replaced.
Closure Date:
5 We recommended that the facility establish a policy addressing radiation equipment inspection, testing, and maintenance and fluoroscopy quality control and that compliance with the newly established policy be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that designated x-ray and fluoroscopy employees have radiation exposure monitoring completed annually and that compliance be monitored.
Closure Date:
7 We recommended that signs be posted in waiting and procedure rooms within radiology asking female patients to notify staff if they may be pregnant.
Closure Date:
8 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:
9 We recommended that processes be strengthened to ensure that patients/caregivers are provided medication lists at discharge and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that patients/caregivers are provided with discharge instructions and that compliance be monitored.
Closure Date:
11 We recommended that nursing managers monitor the staffing methodology that was implemented in August 2013.
Closure Date:
12 We recommended that nurse managers reassess the target nursing hours per patient day for unit 4 East to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
13 We recommended that the facility establish an interprofessional pressure ulcer committee.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
17 We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that patient care areas are clean, that clean and dirty items are stored separately, and that medications are secured at all times and that compliance be monitored.
Closure Date:
19 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.
Closure Date:
20 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for resident transfers.
Closure Date:
21 We recommended that processes be strengthened to ensure that staff do not provide medical treatment to residents during meals in the common dining area.
Closure Date:
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| 14-00687-155 | Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group meet monthly.
Closure Date:
2 We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
Closure Date:
5 We recommended that the facility implement their plan to track OPPEs and present them to the Professional Standards Board within the timeframe required by local policy and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all MSIT members and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response time.
Closure Date:
8 We recommended that the locked MH units' seclusion room floors have a cushioned surface.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology implemented in October 2013.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Closure Date:
13 We recommended that processes be strengthened to ensure that inspection documentation includes the time of the inspection and the time when corrective actions occurred.
Closure Date:
14 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are consistently conducted and documented in Infection Control Committee minutes.
Closure Date:
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| 12-00177-138 | Audit of the Quick Start Program | Audit | ||
1 We recommend the Under Secretary for Benefits establish Veterans Service Network Operations Report capabilities to track claims from the date the Veterans Benefits Administration receives and establishes active servicemembers’ claims to the date of Servicemembers’ discharge from military service.
2 We recommend the Under Secretary for Benefits track and report claims-processing time prior to Servicemembers’ discharge in timeliness performance results for the Quick Start Program or its successor.
3 We recommend the Under Secretary for Benefits conduct recurring evaluations that identify needed staffing adjustments to ensure sufficient staff are allocated to accomplish the timeliness targets of the Quick Start Program or its successor.
4 We recommend the Under Secretary for Benefits require Consolidated Processing Site and intake site claims assistants staff obtain periodic training on identifying and processing claims submitted through the Quick Start Program or its successor.
5 We recommend the Under Secretary for Benefits modify Systematic Technical Accuracy Reviews to include a systematic review of claims processed through the Quick Start Program or its successor.
6 We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to analyze trends of systemic issues identified during Quality Review Team and Systematic Technical Accuracy Review evaluations of claims processed through the Quick Start Program or its successor.
7 We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to provide staff recurring training on systemic issues identified during trend analyses of Quality Review Team and Systematic Technical Accuracy Review results.
8 We recommend the Under Secretary for Benefits revise policies and procedures to clarify that evidence must establish a nexus linking veterans’ claimed conditions to military service regardless of diagnosis proximity to discharge.
9 We recommend the Under Secretary for Benefits require Consolidated Processing Site managers to ensure staff adhere to Veterans Benefits Administration policies related to service connection while processing claims received through the Quick Start Program or its successor.
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| 14-00685-156 | Combined Assessment Program Review of the VA Montana Health Care System, Fort Harrison, Montana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the MEC document its discussion of unusual findings or patterns from PRC quarterly summary reports.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
3 We recommended that the facility have a Surgical Work Group that meets monthly, includes the COS as a member, and documents its review of National Surgical Office reports.
Closure Date:
4 We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
Closure Date:
5 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians provide discharge instructions on all aftercare needs to patients and/or caregivers and document this in the EHR and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
Closure Date:
9 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
Closure Date:
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| 14-00657-144 | Interim Report - VBA's Efforts to Effectively Obtain Service Treatment Records and Official Military Personnel Files | Audit | ||
1 We recommend the Under Secretary for Benefits identify and implement options to help alleviate the file storage issues at the regional office in St. Petersburg, FL.
Closure Date:
2 We recommend the Under Secretary for Benefits ensure mailroom personnel date stamp service treatment record files and copies of official military personnel files on the day they are received at the regional office in St. Petersburg, FL.
Closure Date:
3 We recommend the Under Secretary for Benefits identify and implement options to improve timeliness of evidence mail processing at the regional office in St. Petersburg, FL.
Closure Date:
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| 14-00688-162 | Combined Assessment Program Review of the Canandaigua VA Medical Center, Canandaigua, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC Work Group minutes reflect that actions are taken in response to identified deficiencies.
Closure Date:
2 We recommended that the facility establish a policy for the safe use of fluoroscopic equipment and that compliance with the newly established policy be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that all designated x-ray/fluoroscopy employees receive annual fluoroscopy safety training.
Closure Date:
4 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
5 We recommended that processes be strengthened to ensure that restorative nursing staff consistently document weekly and monthly notes according to local policy and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that providers are notified of critical laboratory and abnormal radiology test results/values within the expected timeframe and that notification is documented in the EHRs.
Closure Date:
7 We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the EHRs.
Closure Date:
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15039