Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-03620-102 | Combined Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that the Surgical Work Group meet monthly, include the Chief of Staff and VASQIP nurse as members, and document its review of National Surgical Office reports.
Closure Date:
3 We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on the 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:
4 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:
5 We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scales daily, upon transfer, and at discharge and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stages and revise treatment plans when risk levels change and that compliance be monitored.
Closure Date:
7 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:
| ||||
| 13-03422-99 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
2 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
3 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
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.
5 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
6 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
| ||||
| 14-00306-95 | Combined Assessment Program Review of the VA Eastern Colorado Health Care System,Denver, Colorado | 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 timely.
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 Surgical Work Group meet monthly and include the Chief of Staff as a member.
Closure Date:
4 We recommended that the nurse staffing methodology be implemented.
Closure Date:
5 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
6 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:
7 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:
8 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:
9 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:
10 We recommended that processes be strengthened to ensure that there are no unnecessary disruptions during resident meal periods.
Closure Date:
| ||||
| 14-00223-93 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Eastern Colorado Health Care System, Denver, Colorado | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
2 We recommended that all staff document that medication reconciliation was completed at each episode of care when the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
3 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
| ||||
| 13-03419-90 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Atlanta VA Medical Center, Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic alarms are tested and testing is documented.
Closure Date:
2 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
| ||||
| 14-00228-94 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Overton Brooks VA Medical Center, Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that all identified environment of care deficiencies at the Monroe CBOC are reported to and tracked by the parent facility Executive Safety Committee until resolution.
2 We recommended that the parent facility include staff at the Monroe CBOC in required education, training, planning, and participation in annual disaster exercises.
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 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 patient’s level of understanding for the medication education.
| ||||
| 13-03549-92 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
| ||||
| 14-00233-96 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Caribbean Health Care System, San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that the hazardous materials inventory for the Arecibo CBOC is reviewed at least twice yearly.
Closure Date:
2 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Arecibo CBOC to the parent facility.
Closure Date:
3 We recommended that managers ensure that women veterans can access gender-specific restrooms without entering public areas at the Arecibo CBOC.
Closure Date:
4 We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
Closure Date:
| ||||
| 13-03653-91 | Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the PRC.
Closure Date:
2 We recommended that the PRC submit quarterly summary reports to the MEC and that the MEC document its discussion of the reports.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and collects code data.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly and document its review of required performance data elements and National Surgical Office reports.
Closure Date:
5 We recommended that the quality control policy for scanning include how to annotate a scanned image to identify that it has been scanned.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Anesthesia Service representative attends Blood Usage Committee meetings and that the blood/transfusion usage review process includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
Closure Date:
7 We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that all locked MH unit staff, MSIT members, and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, the 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:
9 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response times.
Closure Date:
10 We recommended that the locked MH unit¿s seclusion room door open towards the hallway and that patients in seclusion have privacy while using the bathroom.
Closure Date:
11 We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
Closure Date:
12 We recommended that all members of CLC-2's unit-based expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
13 We recommended that the newly established interprofessional pressure ulcer committee continue to meet and that the committee provide oversight of the facility's pressure ulcer prevention program.
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 perform and document daily risk scales 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 acute care staff perform and document daily skin inspections for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
Closure Date:
17 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:
18 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education to patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that all employees who perform restorative nursing services receive training on and competency assessment for ROM and resident transfers.
Closure Date:
| ||||
| 13-03623-89 | Combined Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the ICU Committee reviews each code episode.
Closure Date:
2 We recommended that the MRC analyze all reports of EHR quality review results
Closure Date:
3 We recommended that processes be strengthened to ensure that a member from Surgery Service attends Ancillary Testing Committee meetings, that a clinical representative from Anesthesia Service is added as an Ancillary Testing Committee member, and that the blood/transfusions usage review process includes the results of peer reviews when transfusions did not meet criteria.
Closure Date:
4 We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
Closure Date:
5 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:
6 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff provide timely restorative nursing services to residents who are candidates for those services and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify interventions as needed, and document the modifications and that compliance be monitored.
Closure Date:
| ||||
15039