Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-03650-53 | Combined Assessment Program Review of the Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Chief of Staff reconsider PRC membership to ensure that sufficient experienced senior physicians are regular members.
Closure Date:
2 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:
3 We recommended that processes be strengthened to ensure that CPR 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 the OR Committee (the Surgical Work Group) meet monthly and include the Chief of Staff as a member.
Closure Date:
5 We recommended that processes be strengthened to ensure that the recipient list for the automated e-mail notification for critical incidents is kept current.
Closure Date:
6 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly and that the review of EHR quality includes most services.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings and that the blood/transfusions usage review process includes the results of inspections by government or private (peer) entities and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
8 We recommended that the locked MH unit nursing station have a panic alarm system.
Closure Date:
9 We recommended that processes be strengthened to ensure that acute care staff accurately document risk scale scores for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales and revise prevention plans when risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
11 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 pressure ulcers and patients with pressure ulcers and that staff provide and document recommended interventions 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 applicable consults are completed for patients at risk for and with pressure ulcers and that compliance be monitored.
Closure Date:
14 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:
15 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
16 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:
17 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:
18 We recommended that processes be strengthened to ensure that staff document resident progress using the required Restorative Weekly Note.
Closure Date:
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| 13-02641-50 | Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that Environmental Management Service closets are secured at all times.
Closure Date:
2 We recommended that processes be strengthened to ensure that ceiling tiles are promptly replaced and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that contractors receive OSHA Construction Safety training prior to project initiation.
Closure Date:
4 We recommended that processes be strengthened to ensure construction sites are secured against unauthorized access and that compliance be monitored.
Closure Date:
5 We recommended that the cause of the pooling water outside the shower on unit 7A be fixed and the identified handicapped bathroom door on unit 7A be hung correctly and that processes be strengthened to ensure that units 7A, 8A, 8B, and 39A are clean and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that monthly self-inspections are conducted on all MH RRTP units and documented and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that medications in resident rooms on units 7A, 8A, and 8B are secured and that compliance be monitored.
Closure Date:
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| 13-03649-52 | Combined Assessment Program Review of the Michael E. DeBakey VA Medical Center, Houston, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the COS be appointed as the chairperson of the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that
FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the MEC.
Closure Date:
3 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:
4 We recommended that the Operating Room Committee include the COS as a member.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient care areas and restrooms are clean and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that damaged towel dispensers, doors and doorframes, and floors and baseboards are repaired and that ongoing maintenance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that all locked MH unit staff and MSIT members 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 the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
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 the restorative nursing initial weekly assessment is documented and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
Closure Date:
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| 13-03421-49 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at White River Junction VA Medical Center, White River Junction, Vermont | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that PII is protected by appropriately securing laboratory specimens during transport from the Brattleboro CBOC to the White River Junction VA Medical Center.
Closure Date:
2 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
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:
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| 13-03414-46 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Central Iowa Health Care System, Des Moines, Iowa | 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 Marshalltown CBOC.
Closure Date:
2 We recommended that sharps containers are secured at the Fort Dodge CBOC.
Closure Date:
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| 13-03417-34 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Portland VA Medical Center, Portland, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a separate room is provided to store medical (infectious) waste at the Salem CBOC.
Closure Date:
2 We recommended that signage is installed at the North Coast CBOC to clearly identify the location of fire extinguishers.
Closure Date:
3 We recommended that the IT server closet at the North Coast CBOC is maintained according to IT safety and security standards.
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 MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
6 We recommended that CBOC/PCC staff document medication reconciliation that includes the newly prescribed fluoroquinolone in the EHR.
Closure Date:
7 We recommended that CBOC/PCC staff provide and document medication counseling/education that includes the fluoroquinolone.
Closure Date:
8 We recommended that CBOC/PCC staff document the evaluation of patient's level of understanding for the medication education.
Closure Date:
9 We recommended that the Chief of Staff consistently ensure that all DWHPs are designated with the WH indicator in the PCMM.
Closure Date:
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| 13-03418-44 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Lexington VA Medical Center, Lexington, Kentucky | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Berea CBOC to the parent facility.
Closure Date:
2 We recommended that CBOC/PCC RN Care Managers complete motivational interviewing training within 12 months of appointment to PACT.
Closure Date:
3 We recommended that CBOC/PCC RN Care Managers complete required health coaching training within 12 months of appointment to PACT.
Closure Date:
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| 13-03651-42 | Combined Assessment Program Review of the El Paso VA Health Care System, El Paso, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group meet monthly
Closure Date:
2 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes a review of the history of any previous adverse experience with sedation and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that any changes to informed consents are discussed with and approved by the patients prior to administration of sedation and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that patients who undergo moderate sedation are appropriately monitored during the procedure and that compliance be monitored.
Closure Date:
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| 13-03413-40 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Syracuse VA Medical Center, Syracuse, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that PII is protected by appropriately securing laboratory specimens during transport from the Watertown CBOC to the Syracuse VA Medical Center.
Closure Date:
2 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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:
4 We recommended that staff document that medication reconciliation was completed at each episode of care where medications were administered, prescribed, or modified.
Closure Date:
5 We recommended that CBOC staff consistently document that written medication information is provided to patients when fluoroquinolone antibiotics are prescribed.
Closure Date:
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| 13-03415-31 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Michael E. DeBakey VA Medical Center Houston, Texas | 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 RN Care Managers receive MI training within 12 months of appointment to PACT.
Closure Date:
3 We recommended that CBOC/PCC RN Care Managers receive health coaching training within 12 months of appointment to PACT.
Closure Date:
4 We recommended that CBOC/PCC staff document that medication reconciliation was completed at each episode of care where medications were administered, prescribed, modified or may influence care given.
Closure Date:
5 We recommended that CBOC/PCC staff document the evaluation of patient's level of understanding for the medication education.
Closure Date:
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15039