Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00234-125 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Lebanon VA Medical Center, Lebanon, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months at the Reading CBOC.
Closure Date:
2 We recommended that CBOC and PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that CBOC and PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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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| 14-00658-121 | Combined Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Blood Usage Review Sub-Committee include a clinical representative from Medicine Service as a member.
Closure Date:
2 We recommended that processes be strengthened to ensure that EOC Committee minutes consistently reflect EOC findings from community based outpatient clinic inspections.
Closure Date:
3 We recommended that processes be strengthened to ensure patient care areas are clean and that water leaks and subsequent structural damage are addressed and resolved timely and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that expired medical supplies and medications are removed from patient care areas and that compliance be monitored.
Closure Date:
6 We recommended that all emergency exits on the locked MH unit be alarmed.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the EHRs and that they validate patients' and/or caregivers' understanding of the discharge instructions they provided and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services.
Closure Date:
9 We recommended that the annual staffing plan reassessment process ensures that unit 2NE's and unit 4SW's unit-based expert panels include all required members and that all members of the unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
10 We recommended that nurse managers reassess the target nursing hours per patient day for unit 2NE to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer and that compliance be monitored.
Closure Date:
12 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:
13 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:
14 We recommended that processes be strengthened to ensure that 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:
15 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.
Closure Date:
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| 14-00309-118 | Combined Assessment Program Review of the Portland VA Medical Center, Portland, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Operative Care Division Quality and Performance Group meet monthly, include the COS as a member, and document its review of National Surgical Office reports.
Closure Date:
2 We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
Closure Date:
3 We recommended that all emergency exits on the locked MH unit be alarmed.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinicians conducting medication counseling accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
Closure Date:
8 We recommended that the facility have a Veterans Health Education Coordinator.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
Closure Date:
10 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:
11 We recommended that processes be strengthened to ensure that acute care staff document stage for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that acute care staff consistently document required pressure ulcer information and that compliance be monitored.
Closure Date:
13 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:
14 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:
15 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
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| 13-02053-119 | Healthcare Inspection – Questionable Cardiac Interventions and Poor Management of Cardiovascular Care, Edward Hines, Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that cardiologists performing coronary interventions and surgeons performing cardiac surgery adhere to accepted standards of care.
2 We recommended that the Facility Director ensure that adequate equipment is available in the operating room in accordance with VHA policy.
3 We recommended that the Facility Director ensure that processes are strengthened to improve bed utilization.
4 We recommended that the Facility Director ensure that processes are strengthened to ensure contract oversight in accordance with VA requirements.
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| 14-00659-111 | Combined Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the PRC’s membership be revised to ensure that sufficient experienced senior physicians are regular members.
Closure Date:
2 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently reported to the PRC.
Closure Date:
3 We recommended that the Surgical Work Group meet monthly.
Closure Date:
4 We recommended that processes be strengthened to ensure that
all critical incidents are reported through the patient incident reporting process.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Blood Utilization Review Committee members from Surgery and Anesthesia Services consistently attend meetings and that the blood usage review process includes the results of proficiency testing.
Closure Date:
6 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
7 We recommended that processes be strengthened to ensure that EOC and Administrative Executive Board Committee minutes reflect deficiencies identified on the locked MH unit.
Closure Date:
8 We recommended that processes be strengthened to ensure that cabinets containing contrast agents in the radiology area are secured at all times and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that crash cart checks in the radiology area are documented daily and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that all MH unit staff and occasional 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:
11 We recommended that processes be strengthened to ensure that panic alarm testing documentation includes police response times and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that the medication list provided to the patient/caregiver at discharge is reconciled with the dosage and frequency ordered and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that patients are provided with correct information on discharge instructions.
Closure Date:
14 We recommended that processes be strengthened to ensure that patients’ post-hospitalization outpatient appointments are scheduled within the timeframe requested by the discharging physician.
Closure Date:
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| 13-01959-109 | Audit of VHA's Supportive Services for Veteran Families Program | Audit | ||
1 We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program implement a mechanism to inform grantees when updated area median income limits are published.
Closure Date:
2 We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program grantees follow up to obtain the required Certificate of Release or Discharge from Active Duty (DD 214) when interim documents are used to determine program eligibility.
Closure Date:
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| 14-00232-110 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Loma Linda Healthcare System, Loma Linda, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Rancho Cucamonga CBOC to the VA Loma Linda Healthcare System.
Closure Date:
2 We recommend that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
Closure Date:
4 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that CBOC/PCC RN Care Managers receive motivational interviewing training within 12 months of appointment to PACT.
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 provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
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| 13-02073-106 | Healthcare Inspection – Administrative Irregularities, Leadership Lapses, and Quality of Care Concerns, VA Central Iowa Health Care System, Des Moines, Iowa | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated System Network Director ensure that the Chief of Staff appoints a director of the specific unit of the subject Service Line, who meets the qualification standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee.
2 We recommended that the Facility Director ensure that selection of physicians who will be participating in medical educational activities is conducted within the standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee and that compliance be monitored.
3 We recommended that the Facility Director ensure the implementation of a standardized process for the management of cardiology consults, consistent with VHA policy.
4 We recommended that the Facility Director ensure processes be strengthened so that Focused Professional Practice Evaluations for licensed independent practitioners are consistently conducted as required, and that compliance is monitored.
5 We recommended that the Facility Director ensure that the Chief of Staff maintain a comprehensive list of staff that is authorized to perform out of Operating Room airway management in compliance with facility policy.
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| 14-00308-105 | Combined Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed.
Closure Date:
2 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that the Blood Utilization Review Committee include a clinical representative from Surgery Service.
Closure Date:
4 We recommended that processes be strengthened to ensure that corrective actions are initiated and/or consistently followed to resolution when data analyses indicated problems or opportunities for improvement in the Performance Improvement, Medical Executive, and Executive Safety Committees.
Closure Date:
5 We recommended that processes be strengthened to ensure that patient care areas and restrooms are clean and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that holes in the walls are repaired and that ongoing maintenance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that all locked MH unit staff 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:
8 We recommended that the annual staffing plan reassessment process ensures that unit 6E's and unit 9E's unit-based expert panels include all required members.
Closure Date:
9 We recommended that processes be strengthened to ensure that Interprofessional Skin Integrity Committee minutes include data analysis.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score 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:
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| 13-03089-104 | Healthcare Inspection – Unexpected Patient Death in a Substance Abuse Residential Rehabilitation Treatment Program, Miami VA Healthcare System, Miami, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that the camera surveillance system is repaired and maintained and that surveillance is conducted as required on the SARRTP unit.
Closure Date:
2 We recommended that the System Director ensure that the SARRTP unit is appropriately staffed at all times, as required by VHA and local policy.
Closure Date:
3 We recommended that the System Director ensure that SARRTP staff implement a consistent and comprehensive approach to check patients returning to the unit for contraband and document results clearly.
Closure Date:
4 We recommended that the System Director ensure that SARRTP staff more aggressively monitor patients for illicit drug use, to include increasing the use of random UDS and adhering to local and VHA policy when patients leave the unit.
Closure Date:
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15039