Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00684-132 | Combined Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
Closure Date:
2 We recommended that the MEC discuss and document its approval of the use of another facility's physicians for teledermatology services.
Closure Date:
3 We recommended that the facility obtain teledermatology physicians' professional practice evaluation information from the providing facility.
Closure Date:
4 We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Acute Care Committee reviews each code episode and that code reviews consistently 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 recipient list for the automated e-mail notification for the patient incident reporting process is kept current.
Closure Date:
7 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
Closure Date:
8 We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
Closure Date:
9 We recommended that processes be strengthened to ensure that a member from Anesthesia Service attends Transfusion Utilization Committee meetings and that the blood/transfusions usage review process consistently includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
10 We recommended that the facility comply with VHA and local smoking policies and that compliance be monitored.
Closure Date:
11 We recommended that the VISN 11 Director establish a non-facility team to conduct a comprehensive EOC evaluation of the facility and ensure that deficiencies are corrected and that an action plan is developed to ensure the facility is properly cleaned and maintained.
Closure Date:
12 We recommended that the facility establish a policy for equipment inspection and testing and that compliance with the newly established policy be monitored.
Closure Date:
13 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:
14 We recommended that processes be strengthened to ensure that expired medications are removed from radiology crash carts and clinical staff are trained on how to locate the crash cart expiration date and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on identifying and correcting environmental hazards, content and 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:
16 We recommended that the facility establish an interprofessional pressure ulcer committee.
Closure Date:
17 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
Closure Date:
18 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:
19 We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
20 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:
21 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
22 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:
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| 14-00240-129 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Southern Arizona VA Health Care System, Tucson, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Casa Grande CBOC.
Closure Date:
2 We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Casa Grande, Green Valley, and Safford CBOCs.
Closure Date:
3 We recommended that the information technology server closets at the Green Valley and Safford CBOCs are maintained according to information technology safety and security standards.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
5 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coach training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 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:
7 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Closure Date:
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| 14-00241-128 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at El Paso VA Health Care System, El Paso, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that external signage clearly identifies the building as a VA CBOC at the Eastside El Paso CBOC.
Closure Date:
2 We recommended that testing of the panic alarm system is documented at the Eastside El Paso CBOC.
Closure Date:
3 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
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 consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
7 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
8 We recommended that staff document the evaluation of patient¿s level of understanding for the medication education.
Closure Date:
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| 14-00683-130 | Combined Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of completed FPPEs for newly hired licensed independent practitioners are consistently reported to the MEC.
Closure Date:
2 We recommended that processes be strengthened to ensure that Transfusion Committee members from Surgery and Anesthesia Services consistently attend meetings.
Closure Date:
3 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated after initial use and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that all locked MH unit staff, ISIT 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:
6 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing includes VA Police response time and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that MH EOC Checklist inspections include participation by all required ISIT members and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that the ISIT assigns a risk level per identified deficiency at the time of acute MH unit inspections and that compliance be monitored.
Closure Date:
9 We recommended that nursing managers implement VHA's staffing methodology.
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 perform and document daily skin inspections and daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that all designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that staff do not provide medical treatments to residents during meals in the common dining area.
Closure Date:
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| 14-00239-127 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern Indiana Health Care System, Fort Wayne, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Community Based Outpatient Clinic/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that Community Based Outpatient Clinic/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 that includes the fluoroquinolone.
Closure Date:
6 We recommended that clinical executive/primary care leaders ensure that Community Based Outpatient Clinic/Primary Care Clinic Designated Women’s Health Providers maintain proficiency as required for the provision of women’s health care.
Closure Date:
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| 13-02267-124 | Audit of VHA's Engineering Service Purchase Card Practices at the Ralph H. Johnson VAMC, Charleston, SC | Audit | ||
1 We recommend the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 to identify unauthorized commitments, and submit ratification requests for the unauthorized commitments identified by the Office of Inspector General and by Veterans Integrated Service Network 7 to the Veterans Health Administration Head of Contracting Activity.
Closure Date:
2 We recommended the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high-risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 for purchases lacking sufficient documentation and take steps to recover identified inappropriate payments.
Closure Date:
3 We recommended the Veterans Integrated Service Network 7 Director develop monitoring mechanisms to ensure Charleston VA Medical Center Engineering Service approving officials consistently use Veterans Health Administration’s required Approving Official Checklist to identify split purchases, purchases that exceed the micro-purchase limit for services, and purchases without sufficient documentation.
Closure Date:
4 We recommended the Veterans Integrated Service Network 7 Director ensure Charleston VA Medical Center Engineering Service’s purchase cardholders and approving officials receive required refresher training every 2 years.
Closure Date:
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| 14-00307-126 | Combined Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the MEC document discussion of PRC quarterly summary reports.
2 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the MEC.
3 We recommended that the facility monitor compliance with the new observation bed policy.
4 We recommended that processes be strengthened to ensure that data about observation bed use continues to be gathered.
5 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of the patients in acute beds.
6 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode, that code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code, and that code data is collected.
7 We recommended that the Surgical Work Group meet monthly and document its review of required monthly and quarterly performance data elements, including local performance data and National Surgical Office reports.
8 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
9 We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
10 We recommended that processes be strengthened to ensure that members from Medicine, Surgery, and Anesthesia Services attend Transfusion Process Committee meetings and that the blood/transfusions usage review process includes the results of proficiency testing.
11 We recommended that processes be strengthened to ensure that Infection Control Committee minutes reflect follow-up on actions that were implemented to address identified problems.
12 We recommended that nursing managers continue to monitor the staffing methodology that was implemented in November 2012.
13 We recommended that the facility monitor compliance with the revised pressure ulcer policy as it pertains to prevention for outpatients.
14 We recommended that the newly established Interprofessional Pressure Ulcer Committee meet as required and that the committee provide oversight of the facility’s pressure ulcer prevention program.
15 We recommended that processes be strengthened to ensure that pressure ulcer data is analyzed and that program data is reported to facility executive leadership.
16 We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
17 We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stage in initial skin assessments for patients at risk or with pressure ulcers and that compliance be monitored.
18 We recommended that processes be strengthened to ensure that acute care staff develop interprofessional treatment plans for all hospitalized patients identified as being at risk for or with pressure ulcers and that compliance be monitored.
19 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
20 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.
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| 13-02926-112 | FY 2013 Review of VA's Compliance With the Improper Payments Elimination and Recovery Act | Audit | ||
1 We recommended the Under Secretary for Health implement the corrective action plan included in the Performance and Accountability Report to reduce improper payments for the State Home Per Diem program.
Closure Date:
2 We recommended the Under Secretary for Health develop achievable reduction targets for the State Home Per Diem and Beneficiary Travel programs.
Closure Date:
3 We recommended the Under Secretary for Benefits ensure thorough procedures for testing sample items used to estimate improper payments for the Compensation and Post 9/11 G.I. Bill programs.
Closure Date:
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| 13-02649-120 | Administrative Investigation, Failure to Comply with Americans with Disabilities Act and VA Policy, Veterans Health Administration | Administrative Investigation | ||
1 We recommend that the Deputy Under Secretary for Health Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Director.
Closure Date:
2 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
Closure Date:
3 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the Director.
Closure Date:
4 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
Closure Date:
5 We recommend that the DUSHOM confer with OGC and OHRI to determine and execute a plan to provide all VHA employees involved in the RA process, as well as Regional Counsels who provide them advice, the most up to date RA training and guidance, and direct all VHA employees to process RA requests in accordance with applicable Federal laws and regulations and VA policy.
Closure Date:
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| 14-00305-123 | Combined Assessment Program Review of the Southern Arizona VA Health Care System, Tucson, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
2 We recommended that the Surgical Work Group meet monthly.
Closure Date:
3 We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas in the CLC are clean and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that walls in the CLC are repaired and maintained.
Closure Date:
6 We recommended that processes be strengthened to ensure that all workers who occasionally access the acute MH 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 patient learning assessments are conducted and documented and that compliance be monitored.
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 clinicians identify post-discharge needs and include them in discharge planning.
Closure Date:
10 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services within the ordered/expected timeframe.
Closure Date:
11 We recommended that nursing managers monitor the staffing methodology that was implemented in May 2013.
Closure Date:
12 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
13 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
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 revise the prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
Closure Date:
17 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:
18 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 conduct a complete skin assessment and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that staff document weekly summaries of restorative nursing services in residents’ EHRs.
Closure Date:
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15039