Recommendations
2108
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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:
| ||||
| 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.
| ||||
15211