Recommendations
2107
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 13-00026-08 | Community Based Outpatient Clinic Reviews at Richard L. Roudebush VA Medical Center, Indianapolis, IN | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
5 We recommended that handicap parking spaces meet ADA requirements at the Terre Haute CBOC.
Closure Date:
6 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and that all identified issues are tracked, trended, and corrected at the Terre Haute CBOC.
Closure Date:
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| 13-00026-07 | Community Based Outpatient Clinic Reviews at VA Greater Los Angeles Healthcare System, Los Angeles, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
2 We recommended that the Antelope Valley CBOC IT closet is maintained according to IT security standards.
Closure Date:
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15205