Recommendations
2106
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02315-332 | Combined Assessment Program Review of the Edward Hines, Jr. VA Hospital, Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that ICC minutes reflect discussion of high-risk areas and actions implemented to address these areas.
Closure Date:
2 We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
Closure Date:
3 We recommended that processes be strengthened to ensure that inspectors consistently verify the three identified required drug destruction activities and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
5 We recommended that processes be strengthened to ensure that a contractor tuberculosis risk assessment is conducted prior to construction project initiation.
Closure Date:
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| 12-00366-339 | Audit of NCA's Contracting Practices | Audit | ||
1 We recommend the Under Secretary for Memorial Affairs ensure the Contracting Service establish procedures to ensure contracts are properly awarded according to the Federal Acquisition Regulations.
Closure Date:
2 We recommend the Under Secretary for Memorial Affairs ensure acquisition plans, market research, and evaluations of past performance are properly documented in the contract files.
Closure Date:
3 We recommend the Under Secretary for Memorial Affairs ensure Contracting Service establish procedures to ensure competitive procurement methods are used to the maximum extent possible.
Closure Date:
4 We recommend the Under Secretary for Memorial Affairs coordinate with the Office of Acquisition, Logistics, and Management to resolve Electronic Contract Management System issues to ensure system capabilities are fully used.
Closure Date:
5 We Recommend the Under Secretary for Memorial Affairs ensure Contracting Service fully implements the Integrated Oversight Process and ensure required contract reviews are conducted before awarding contracts.
Closure Date:
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| 13-00026-327 | Community Based Outpatient Clinic Reviews at Chalmers P. Wylie Ambulatory Care Center, Columbus, OH | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
4 We recommended that managers develop a local policy for MH emergencies that reflects the CBOC’s capability and that staff is trained in the procedural steps of the MH emergency plan.
Closure Date:
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| 13-01855-336 | Healthcare Inspection – Quality of Care Issues, Erie VA Medical Center, Erie, PA, and VA Pittsburgh Healthcare System, Pittsburgh, PA | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible disclosure to the surviving family member(s) of the patient.
Closure Date:
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| 13-02316-322 | Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
Closure Date:
2 We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
Closure Date:
4 We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
Closure Date:
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge and that compliance be monitored.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, and daily monitoring for a change in condition for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff perform and document daily monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
Closure Date:
16 We recommended that the facility establish staff pressure ulcer education requirements and that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
Closure Date:
17 We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
Closure Date:
18 We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
20 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
21 We recommended that processes be strengthened to ensure that all designated employees complete respirator fit testing and that compliance be monitored.
Closure Date:
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| 13-00026-316 | Community Based Outpatient Clinic Reviews at Sheridan VA Healthcare System, Sheridan, WY | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that MSDS are kept current at the Casper and Riverton CBOCs and that staff is trained in accessing MSDS for hazardous chemicals in the clinical area at the Casper CBOC.
Closure Date:
3 We recommended that managers ensure all exit routes are clearly identified at the Riverton CBOC.
Closure Date:
4 We recommended that testing of the panic alarm system is documented at the Casper and Riverton CBOCs.
Closure Date:
5 We recommended that the Chief of OI&T implements required measures at the Casper CBOC.
Closure Date:
6 We recommended that EOC deficiencies are tracked, trended, and corrected at the Casper and Riverton CBOCs.
Closure Date:
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| 12-03887-319 | Healthcare Inspection – Inadequate Staffing and Poor Patient Flow in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop action plans that address emergency department patient flow and length of stay, including specialty bed access.
Closure Date:
2 We recommended that the Facility Director develop an emergency department staffing policy that includes a contingency plan for additional physician and nurse staffing when patient care demands exceed available staffing resources.
Closure Date:
3 We recommended that the Facility Director ensure that data collection and the reporting process are strengthened.
Closure Date:
4 We recommend that the Facility director ensure that a local diversion policy is developed and implemented.
Closure Date:
5 We recommended that the Facility Director ensure that the patient flow committee meets regularly, membership is reviewed for appropriateness, and follow-up actions are monitored.
Closure Date:
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| 12-02708-301 | Review of Alleged System Duplication in VA’s Virtual Office of Acquisition Software Development Project | Audit | ||
1 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
Closure Date:
2 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Closure Date:
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| 13-00026-314 | Community Based Outpatient Clinic Reviews at James A. Haley Veterans' Hospital, Tampa, FL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
3 We recommended that managers ensure that fire drills be completed at the Zephyrhills CBOC as required.
Closure Date:
4 We recommended that managers ensure that signage is installed at the New Port Richey and Zephyrhills CBOCs that clearly identifies fire extinguisher locations.
Closure Date:
5 We recommended that managers ensure that patient privacy is maintained as required at the New Port Richey and Zephyrhills CBOCs.
Closure Date:
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| 13-01498-318 | Healthcare Inspection – An Unexpected Death in a Mental Health Treatment Program, VA New Jersey Health Care System, Lyons, New Jersey | Hotline Healthcare Inspection | ||
1 We recommended that that the Health Care System Director ensures that the Mental Health Residential Rehabilitation Treatment Program complies with local and VHA Mental Health Residential Rehabilitation Treatment Program Safe Medication Management policy requirements.
Closure Date:
2 We recommended that the Health Care System Director ensure that Mental Health Residential Rehabilitation Treatment Program documentation is individualized, timely, and includes required elements.
Closure Date:
3 We recommended that the Health Care System Director ensure that Mental Health leadership provides appropriate professional support for Mental Health Residential Rehabilitation Treatment Program mid-level providers.
Closure Date:
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15200