Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02314-39 | Combined Assessment Program Review of the Carl Vinson VA Medical Center, Dublin, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the senior-level committee responsible for QM and performance improvement include the facility Director as a member.
2 We recommended that senior leaders routinely discuss the facility’s IPEC data and ensure that discussions are documented in the minutes of a senior-level committee.
3 We recommended that the facility Director ensure that the peer review process meets applicable requirements and is monitored on an ongoing basis and that documented evidence of compliance be readily available.
4 We recommended that the local observation bed policy be revised to include that each observation patient must have a focused goal for the period of observation and that each admission must have a clinical condition that is appropriate for observation.
5 We recommended that the facility Director ensure that the observation bed review process meets applicable requirements and is monitored on an ongoing basis and that documented evidence of compliance be readily available.
6 We recommended that the facility Director ensure that the cardiopulmonary resuscitation review process meets applicable requirements and is monitored on an ongoing basis and that documented evidence of compliance be readily available.
7 We recommended that the facility Director ensure that the EHR quality review process meets applicable requirements and is monitored on an ongoing basis and that documented evidence of compliance be readily available.
8 We recommended that the facility Director ensure that the blood usage review process meets applicable requirements and is monitored on an ongoing basis and that documented evidence of compliance be readily available.
9 We recommended that processes be strengthened to ensure that representatives from Surgery, Medicine, and Anesthesia Services attend Blood Usage Committee meetings.
10 We recommended that processes be strengthened to ensure that Medical Executive Committee and Quality Leadership Team minutes reflect discussion of improvement opportunities and track actions taken to completion for IPEC data and the copy and paste function.
11 We recommended that the facility conduct a full evaluation of QM processes to determine whether improvements are needed to ensure a comprehensive and effective program that monitors all required components.
12 We recommended that processes be strengthened to ensure that vents in patient care areas are clean and that compliance be monitored.
13 We recommended that processes be strengthened to ensure that RME standard operating procedures and manufacturers’ instructions are consistent.
14 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates or refresher training.
15 We recommended that processes be strengthened to ensure that monthly inspections of all non-pharmacy areas with CS are conducted and include all required elements and that compliance be monitored.
16 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy areas are conducted and include all required elements and that compliance be monitored.
17 We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
18 We recommended that the facility establish an interprofessional pressure ulcer committee with appropriate membership, including a certified wound care specialist.
19 We recommended that the facility analyze pressure ulcer data and report it to facility executive leadership.
20 We recommended that processes be strengthened to ensure that acute care staff perform and document a complete skin assessment on all patients within 24 hours of admission and that compliance be monitored.
21 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.
22 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.
23 We recommended that processes be strengthened to ensure that acute care staff consistently perform and document daily risk scales and daily skin inspections for patients at risk for or with pressure ulcers and that compliance be monitored.
24 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.
25 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.
26 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.
27 We recommended that processes be strengthened to ensure that IC and tuberculosis risk assessments are conducted and reviewed prior to construction project initiation.
28 We recommended that all required members of the multidisciplinary CSC participate in construction site inspections and that inspection documentation includes the time of the inspection and the names of those who participated.
29 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC minutes.
30 We recommended that processes be strengthened to ensure that CSC minutes contain documentation of any unsafe conditions identified in daily inspections.
31 We recommended that processes be strengthened to ensure that contractors receive OSHA Construction Safety training prior to project initiation.
32 We recommended that processes be strengthened to ensure that designated employees receive initial and ongoing construction safety training and that compliance be monitored.
33 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections are conducted and documented.
34 We recommended that processes be strengthened to ensure that MH RRTP employees perform and document daily bed checks and weekly contraband inspections and that compliance be monitored.
35 We recommended that processes be strengthened to ensure that written agreements acknowledging resident responsibility for medication security are in place.
36 We recommended that the MH RRTP units’ main points of entry have keyless entry systems.
37 We recommended that the facility implement written processes to address behavioral health and medical emergencies and that MH RRTP employees are aware of the actions to be taken.
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| 13-01956-37 | Healthcare Inspection – Quality of Care Issues, San Juan VA Medical Center, San Juan, Puerto Rico | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensures that thorough nutritionalassessments are completed (including weights), plans are implemented, and patient progress is continually monitored.
Closure Date:
2 We recommended that the System Director ensures that processes be strengthenedto ensure that nursing staff perform and document accurate daily skin inspections for all hospitalized patients identified as being at risk for pressure ulcers, and that compliance is monitored.
Closure Date:
3 We recommended that the System Director implement measures to ensure thatdischarge planning processes are appropriate for the patient’s condition, discharge orders comply with local policy, and that compliance is monitored.
Closure Date:
4 We recommended that the System Director implement measures to ensure that theinformed consent process complies with VHA requirements.
Closure Date:
5 We recommended that the System Director consult with Regional Counsel regardingpossible disclosure to the patient and family of failure to diagnose urinary tract infection with sepsis, and failure to prevent and treat pressure ulcers.
Closure Date:
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| 13-03862-35 | Healthcare Inspection – Emergency Department Length of Stay and Call Center Wait Times, VA Eastern Colorado Health Care System, Denver, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network and Facility Directors ensure processes be strengthened to improve Health Information Call Center practices and staffing levels.
Closure Date:
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| 12-04536-308 | Audit of VA's Pharmacy Reengineering Software Development Project | Audit | ||
1 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure all of the time needed to develop and deploy each remaining Pharmacy Reengineering increment, to include the initial operating capability phase, is reported and monitored on the Project Management Accountability System Dashboard.
Closure Date:
2 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, develop guidance and a reliable methodology for capturing and reporting planned and actual project costs at the increment level on the Project Management Accountability System Dashboard for the remaining increments of Pharmacy Reengineering software development.
Closure Date:
3 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish guidance on replanning software development projects that have been paused in sufficient detail to demonstrate that increments of the projects are well thought out and achievable.
Closure Date:
4 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish controls to ensure information technology projects have sufficient leadership and staff assigned throughout the project life cycle.
Closure Date:
5 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish plans on how future Pharmacy Reengineering development will be funded until a decision is made regarding transferring this effort to the Integrated Electronic Health Record project.
Closure Date:
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| 13-00488-26 | Alleged Chemotherapy Delay and Excessive Emergency Department Length of Stay | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that length of stay in the emergency department is reviewed, and that action plans are developed to address excessive length of stay, and that action plans are implemented and monitored for compliance.
Closure Date:
2 We recommended that the Facility Director ensure that the Patient Flow Committee meets as required by local policy, reviews membership to ensure inclusion of frontline staff, that follow-up reports are submitted, and that identified improvement processes are monitored and communicated to all involved staff.
Closure Date:
3 We recommended that the Facility Director ensure that action plans addressing the monitoring and handoff communication of oncology clinic patients waiting for after-hours admission are communicated to involved staff, implemented, and monitored for compliance.
Closure Date:
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| 13-00026-24 | Community Based Outpatient Clinic Reviews at James H. Quillen VA Medical Center, Mountain Home, TN | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients are notified of cervical cancer screening results within the defined timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that fire extinguisher signage is installed at the Morristown CBOC.
Closure Date:
3 We recommended that the facility ensures the exam tables are positioned so that patient privacy is respected at the Rogersville CBOC.
Closure Date:
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| 13-02642-21 | Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the results of FPPEs for newly hired licensed independent practitioners are reported to the MEB.
Closure Date:
2 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed for all services.
Closure Date:
3 We recommended that processes be strengthened to ensure that the EHR copy and paste function is monitored.
Closure Date:
4 We recommended that the facility implement a quality control policy for scanning.
Closure Date:
5 We recommended that processes be strengthened to ensure that all expired medications are removed from patient care areas.
Closure Date:
6 We recommended that processes be strengthened to ensure that lower storage shelves in the distribution storage area are solid and at least 8 inches above the floor.
Closure Date:
7 We recommended that processes be strengthened to ensure that distribution storage area humidity and temperatures are maintained within acceptable levels and that compliance be monitored.
Closure Date:
8 We recommended that facility policy be amended to include that the CS Coordinator and inspectors must be free from conflicts of interest and that the CS Coordinator must have a complete understanding of CS policies and the VHA CS inspection process and to include the requirements for new CS inspector orientation and annual training thereafter.
Closure Date:
9 We recommended that managers initiate actions to address the two identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
10 We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly, that inspections are randomly scheduled and completed on the day initiated, and that inspectors verify hard copy orders for five dispensing activities and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that the main pharmacy vault and pharmacy emergency cache are inspected monthly and that inspections include all required elements and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
14 We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
15 We recommended that facility policy be amended to include that a minimum 0.25 FTE MH professional and an administrative support person be assigned to the PCCT.
Closure Date:
16 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:
17 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers 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 for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
19 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
20 We recommended that nursing managers monitor the staffing methodology that was implemented in August 2013.
Closure Date:
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| 13-02643-20 | Combined Assessment Program Review of the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that Special Care Committee code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the cardiopulmonary event.
Closure Date:
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
3 We recommended that the identified environmental safety hazards on the locked MH unit related to equipment, furniture, and anchor points be corrected and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that all panic alarms on the locked MH unit are tested and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization receive annual competency assessments.
Closure Date:
6 We recommended that processes be strengthened to ensure that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that pharmacy inspections are consistently completed on the same day they were initiated and that compliance be monitored.
Closure Date:
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| 13-00026-10 | Community Based Outpatient Clinic Reviews at Kansas City VA Medical Center, Kansas City, MO | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
4 We recommended that managers ensure that clinicians administer tetanus vaccines when indicated.
Closure Date:
5 We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
Closure Date:
6 We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
7 We recommended that the medical staff’s Executive Committee grants privileges consistent with the services provided at the Belton, Excelsior Springs, and Louisburg-Paola CBOCs.
Closure Date:
8 We recommended that handicap parking spaces, as required by the ADA, are added at the Louisburg-Paola CBOC.
Closure Date:
9 We recommended that the restrooms meet the ADA requirements at the Belton CBOC.
Closure Date:
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| 13-00133-12 | Healthcare Inspection – Alleged Improper Opioid Prescription Renewal Practices, San Francisco VA Medical Center, San Francisco, California | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure providers comply with all elements of the management of chronic pain patients on opioid therapy, as required by VHA and the VA/DoD Clinical Guideline.
Closure Date:
2 We recommended that the Facility Director ensures that the Narcotic Instructions Note is reevaluated for appropriate use in the clinic and that providers comply with established protocol.
Closure Date:
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15039