Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-04331-63 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Boise VA Medical Center, Boise, Idaho | 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 provide education and counseling for patients with a positive alcohol screen and drinking levels above NIAAA limits.
Closure Date:
3 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
5 We recommended that CBOC/PCC RN Care Managers receive MI interviewing and health coaching 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:
8 We recommended that staff document the evaluation of each patient’s level of understanding for the medication education.
Closure Date:
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| 13-03178-70 | Healthcare Inspection – Alleged Lapses in Communication and Poor Quality of Care, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that a process is in place to assure that patient information is shared with patients, families, and significant others in an appropriate manner that protects patient privacy.
Closure Date:
2 We recommended that the Facility Director ensure that processes be strengthened for inventory, documentation, storage, and retrieval of patient belongings, and that compliance is monitored.
Closure Date:
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| 13-03624-58 | Healthcare Inspection – Alleged Patient Safety Concerns in the Operating Room, VA Maine Healthcare System, Augusta, Maine | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop and implement a master staffing plan for the operating room based on Association of Perioperative Registered Nurses recommendations to ensure adequate coverage and support for operating room staff.
Closure Date:
2 We recommended that the Facility Director ensure that the Surgical Work Group and Operating Room Committee are implemented and functioning in accordance with Veterans Health Administration and local policies.
Closure Date:
3 We recommended that the Facility Director implement the recommendations made during a protected Veterans Health Administration Surgical Program review.
Closure Date:
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| 13-04242-61 | Combined Assessment Program Review of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Operative/Invasive Procedures Committee 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 infection prevention risk assessments prioritize risks for acquiring and transmitting infections.
Closure Date:
3 We recommended that processes be strengthened to ensure that orders for mammograms are entered in CPRS and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians screen patients for tetanus vaccinations at clinic visits.
Closure Date:
5 We recommended that processes be strengthened to ensure that clinicians document all required vaccine administration elements and that compliance be monitored.
Closure Date:
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| 13-04240-60 | Combined Assessment Program Review of the White River Junction VA Medical Center, White River Junction, Vermont | 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 processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the CEB.
Closure Date:
3 We recommended that the local observation bed policy be revised to include how the responsible service and provider are determined and that each observation patient must have a focused goal for the period of observation.
Closure Date:
4 We recommended that the Operative and Invasive Procedure Committee meet monthly and include the Chief of Staff as a member.
Closure Date:
5 We recommended that processes be strengthened to ensure that Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
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 nursing managers complete annual staffing plan reassessments timely.
Closure Date:
8 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:
9 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale daily and at discharge and develop interprofessional treatment plans and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer stages, risk scale scores, and wound improvement or deterioration, including wound characteristics, from the time of admission to the time of discharge.
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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| 13-00872-71 | Healthcare Inspection – Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the VISN Director take action to ensure more permanent, stable leadership in key positions.
Closure Date:
2 We recommended that the Facility Director ensure that morbidity outliers are discussed and analyzed, and that corrective actions are taken as indicated.
Closure Date:
3 We recommended that the Facility Director ensure that residents and staff discontinue use of logbooks and utilize approved electronic methods to track and schedule surgical cases.
Closure Date:
4 We recommended that the Facility Director ensure adequate staffing and processes to minimize operating room delays and meet patient care needs.
Closure Date:
5 We recommended that the Facility Director ensure that infection control surveillance data is analyzed and trended, and that Infection Control Sub-Council minutes include required elements and reflect preventive and corrective measures.
Closure Date:
6 We recommended that the Facility Director ensure compliance with VHA guidance regarding identification, reporting, and follow-up of reusable medical equipment reprocessing issues, and that Reusable Medical Equipment committee minutes reflect these and other required elements.
Closure Date:
7 We recommended that the Facility Director improve Supply Processing Services processes to ensure staff are trained and competent in relevant reusable medical equipment reprocessing activities, and that competencies, manufacturer instructions, and standard operating procedures are consistent.
Closure Date:
8 We recommended that the Facility Director ensure that Quality Management oversight and reporting structures are fully integrated, comprehensive, and functional.
Closure Date:
9 We recommended that the Facility Director ensure oversight and subordinate committee minutes include required elements; and reflect data analysis, conclusions, action tracking and follow-up, and outcome measurement.
Closure Date:
10 We recommended that the Facility Director ensure compliance with patient safety program reporting and evaluation policies, and ensure that reportable close calls are clearly defined in local policy.
Closure Date:
11 We recommended that the Facility Director ensure compliance with VHA policies on identification and reporting of cases for peer review, including use of the Occurrence Screening package.
Closure Date:
12 We recommended that the Facility Director ensure the Peer Review Committee complies in a timely manner with VHA guidelines regarding discussion, analysis, tracking, and follow-up of final Peer Review Committee decisions.
Closure Date:
| ||||
| 13-03416-56 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Montana Health Care System, Fort Harrison, Montana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the side entrance door is ADA accessible
at the Cut Bank CBOC.
Closure Date:
2 We recommended that the restroom is ADA accessible at the Cut Bank CBOC.
Closure Date:
3 We recommended that processes are improved to ensure review
of the hazardous materials inventory occurs twice within a 12-month period for the Cut Bank and Miles City CBOCs.
Closure Date:
4 We recommended that signage is installed at the Cut Bank
CBOC to clearly identify the location of fire extinguishers.
Closure Date:
5 We recommended that signage is installed at the Cut Bank CBOC to clearly identify exits.
Closure Date:
6 We recommended that the IT server closets at the Cut Bank and Miles City CBOCs are maintained according to IT safety and security standards.
Closure Date:
7 We recommended that computer screens are secured to eliminate viewing of PII by unauthorized individuals at the Miles City CBOC.
Closure Date:
8 We recommended that managers ensure that an AED is available at the Miles City CBOC.
Closure Date:
9 We recommended that the parent facility document EMP-specific training completed for the Cut Bank and Miles City CBOCs' clinical providers.
Closure Date:
10 We recommended that the parent facility¿s EMC evaluate the Cut Bank and Miles City CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
Closure Date:
11 We recommended that CBOC/PCC staff consistently complete follow-up assessments for patients with a positive alcohol screen.
Closure Date:
12 We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking levels above NIAAA limits.
Closure Date:
13 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
14 We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
Closure Date:
15 We recommended that CBOC/PCC staff document medication reconciliation that includes the newly prescribed fluoroquinolones in the EHR.
Closure Date:
16 We recommended that CBOC/PCC staff provide and document medication counseling/education that includes the fluoroquinolone.
Closure Date:
17 We recommended that CBOC/PCC staff document the evaluation of patient's level of understanding for the medication education.
Closure Date:
| ||||
| 13-03423-55 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Bogalusa VA Outpatient Clinic designates handicap-accessible parking spaces as required by the ADA.
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 PACTs.
Closure Date:
4 We recommended that staff document that medication reconciliation be completed at each episode of care where the newly prescribed fluoroquinolone is administered, prescribed, or modified.
Closure Date:
5 We recommended that staff document the evaluation of each patient's level of understanding for the medication education provided.
Closure Date:
| ||||
| 13-03621-57 | Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the MEC.
2 We recommended that processes be strengthened to ensure that the Code Blue Committee reviews each code episode.
3 We recommended that processes be strengthened to ensure that nursing managers continue to complete annual staffing plan reassessments timely.
4 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.
| ||||
| 13-03652-59 | Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that all surgical deaths are reviewed by the facility's Surgical Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the critical incident tracking and notification system's recipient list is current.
Closure Date:
3 We recommended that that processes be strengthened to ensure that the Transfusion and Tissue Review Committee member from Anesthesia Service consistently attends meetings.
Closure Date:
4 We recommended that that processes be strengthened to ensure that the CRC meets monthly and includes physician participation.
Closure Date:
5 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the locked MH unit and that MH Risk Assessment and Abatement Tracking data reflect risk levels and tracking of actions to closure for all identified environmental hazards on the locked MH unit.
Closure Date:
6 We recommended that processes be strengthened to ensure that access to emergency exits at the Cooper division is unrestricted and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
Closure Date:
8 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:
9 We recommended that processes be strengthened to ensure that all panic alarms on the locked MH unit are routinely tested and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that all audiovisual equipment on the locked MH unit is properly secured.
Closure Date:
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15039