Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00433-199 | Combined Assessment Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
Closure Date:
2 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
4 We recommended that the quality control process for scanning includes methods to ensure that scanned documents are linked to the correct EHR.
Closure Date:
5 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
Closure Date:
6 We recommended that processes be strengthened to ensure that the WVPM completes the required annual EOC evaluation.
Closure Date:
7 We recommended that processes be strengthened to ensure that identified women's health-related EOC deficiencies are tracked to closure.
Closure Date:
8 We recommended that processes be strengthened to ensure that examination and treatment rooms designated for female patients have door locks.
Closure Date:
9 We recommended that an After Installation Checklist be completed for the ceiling lift in the physical therapy clinic.
Closure Date:
10 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
11 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated in a timely manner.
Closure Date:
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| 13-00887-204 | Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the codes.
Closure Date:
3 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
4 We recommended that the local blood usage policy be revised to define criteria for appropriateness of transfusions and that processes be strengthened to ensure that the blood usage review process includes consistent reporting of transfusion appropriateness; the number of units outdated or discarded; and results of proficiency testing, peer reviews, and inspections.
Closure Date:
5 We recommended that processes be strengthened to ensure that
HPC consult responses are attached to the consult request in the CPRS.
Closure Date:
6 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
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| 13-00026-198 | Community Based Outpatient Clinic Reviews at Sioux Falls VA Health Care System, Sioux Falls, SD | 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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| 13-00026-197 | Community Based Outpatient Clinic Reviews at VA Maine Healthcare System, Augusta, ME | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process be established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted 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 defined timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that patients' PII is protected and secured at the Bangor CBOC.
Closure Date:
4 We recommended that the Chief of OI&T evaluates security of the IT closet and implements required measures at the Bangor CBOC.
Closure Date:
5 We recommended that all identified EOC deficiencies and corrective actions at the Bangor and Calais CBOCs are tracked and trended by the EOC Committee.
Closure Date:
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| 13-00026-196 | Community Based Outpatient Clinic Reviews at Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA | 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 allotted 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 defined timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that the Acting Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
Closure Date:
4 We recommended that laboratory specimens are secured during transport from the CBOCs to the parent facility to prevent the disclosure of patients' PII.
Closure Date:
5 We recommended that all identified EOC deficiencies and corrective actions be tracked and trended by the EOC Committee.
Closure Date:
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| 13-00940-193 | Healthcare Inspection – Alleged Delays in Notifying Patients of Biopsy Results, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement procedures to ensure that patient notifications are timely and documented in patients' electronic health records.
Closure Date:
2 We recommended that the Facility Director ensure that performance improvement processes be strengthened to include periodic monitoring of test result communication to patients.
Closure Date:
3 We recommended that the Facility Director ensure that the facility's written policy on critical test results addresses critical biopsy test results from outpatient procedures.
Closure Date:
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| 13-01320-200 | Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health finalize VHA's Clinical Operations Guideline for 'Implementation of a Large Scale Disclosure Decision' to include a monitoring process that reflects the urgency of disclosing adverse events to patients.
Closure Date:
2 We recommended that the VISN Director review the facts that led to the misuse of insulin pens and take appropriate administrative action.
Closure Date:
3 We recommended that the Facility Director implement a process to ensure the facility's Medication Use, Nursing Practice, and Commodity Standards Committees and other relevant leadership evaluate the risks and benefits before introducing new medical products or supplies that require changes in nursing procedures.
Closure Date:
4 We recommended that the Facility Director strengthen nurse education practices when introducing new medical products or supplies and ensure that all nurses are made aware of how to find and use the facility's nursing practice procedures.
Closure Date:
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| 13-00893-195 | Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates or refresher training.
Closure Date:
3 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
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| 13-00026-191 | Community Based Outpatient Clinic Reviews at Cheyenne VA Medical Center, Cheyenne, WY | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommend that the CBOC IT server closet is maintained according to IT safety and security standards.
Closure Date:
4 We recommended that all identified EOC deficiencies are tracked, trended, and corrected.
Closure Date:
| ||||
| 13-00026-190 | Community Based Outpatient Clinic Reviews at VA New Jersey Health Care System, East Orange, NJ | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the MSEC grants privileges that are consistent with the services provided at the Paterson and Piscataway CBOCs.
Closure Date:
6 We recommended that managers ensure that signage is installed to direct patient to handicapped parking and accessible entrance at the Paterson CBOC.
Closure Date:
7 We recommended that the Chief of OI&T implements, maintains, and reviews IT closet access logs at the Piscataway CBOC.
Closure Date:
8 We recommended that biohazardous waste containers at the Piscataway CBOC are stored appropriately.
Closure Date:
9 We recommended that managers ensure that Paterson and Piscataway CBOC staff are trained and knowledgeable of the CBOC’s MH emergency policy.
Closure Date:
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14917