Recommendations
2145
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00923-237 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | 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 Milo C. Huempfner CBOC.
2 We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Cleveland CBOC.
3 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
4 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
5 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.
6 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.
7 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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| 14-03010-251 | Healthcare Inspection - Improper Closure of Non-VA Care Consults, Carl Vinson VA Medical Center, Dublin, GA | Hotline Healthcare Inspection | ||
1 We recommended that the VISN Director review the circumstances surrounding the batch closures and confer with appropriate VA offices to determine the need for administrative action, if any.
Closure Date:
2 We recommended that the Facility Director track the timeliness of NVCC appointment scheduling and promptly respond to potential delays in care.
Closure Date:
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| 14-01291-241 | Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group consistently meet monthly.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Medicine Service attends meetings.
Closure Date:
3 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:
4 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
5 We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to residents' care plans and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff modify restorative nursing interventions as needed and document the modifications and that compliance be monitored.
Closure Date:
8 We recommended that process be strengthened to ensure that hand-off communication occurs between Physical Medicine and Rehabilitation Service and the community living center when residents are discharged from therapy to ensure that restorative nursing services occur.
Closure Date:
9 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training for range of motion.
Closure Date:
10 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 magnetic resonance imaging and that compliance be monitored.
Closure Date:
11 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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| 14-00727-239 | Combined Assessment Program Summary Report – Evaluation of Hospice and Palliative Care in 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 senior managers, ensures that at least the minimum required Palliative Care Consult Team staffing is provided.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that end-of-life care training is provided to staff who work in areas where they are likely to encounter patients at the end of their lives.
Closure Date:
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| 14-00904-226 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
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 staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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:
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| 14-01501-229 | Inspection of VA Regional Office Des Moines, Iowa | Review | ||
1 We recommend the Des Moines VA Regional Office Director conduct a review of the 131 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the Des Moines VA Regional Office Director implement a plan for an additional level of review of special monthly compensation claims.
Closure Date:
3 We recommend the Des Moines VA Regional Office Director implement a plan to ensure staff follow the policy for the special operations team to process special monthly compensation decisions.
Closure Date:
4 We recommend the Des Moines VA Regional Office Director develop and implement a plan to ensure staff prioritize processing of benefits reductions at the expiration of due process as required.
Closure Date:
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| 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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15427