Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03746-161 | Combined Assessment Program Review of the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPE for newly hired licensed independent practitioners are consistently initiated.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
Closure Date:
4 We recommended that the Consolidation Building have fire extinguisher signage in place in accordance with National Fire Protection Association standards.
Closure Date:
5 We recommended that processes be strengthened to ensure that post-operative patients are transported using clean elevators.
Closure Date:
6 We recommended that processes be strengthened to ensure that non-HPC staff receive end-of-life training.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
8 We recommended that processes be strengthened to ensure that all Home Oxygen Plan of Care notes have a physician co-signature.
Closure Date:
9 We recommended that the construction and renovation activities multidisciplinary committee continues to meet.
Closure Date:
10 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
11 We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results are documented.
Closure Date:
12 We recommended that processes be strengthened to ensure that construction site inspection documentation includes all the required elements.
Closure Date:
13 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are documented in Infection Control Committee minutes.
Closure Date:
14 We recommended that processes be strengthened to ensure that designated employees receive initial and ongoing construction safety training and that compliance be monitored.
Closure Date:
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| 13-01743-192 | Combined Assessment Program Summary Report – Evaluation of Moderate Sedation in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.
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| 13-00026-189 | Community Based Outpatient Clinic Reviews at Northport VA Medical Center, Northport, NY | 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 vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that access is improved for disabled veterans.
Closure Date:
6 We recommended that staff are trained in accessing MSDS for hazardous chemicals in the clinical area.
Closure Date:
7 We recommended that computer screens are secured to eliminate viewing of PII by unauthorized individuals.
Closure Date:
8 We recommended that laboratory specimens are secured during transport from the CBOC to the parent facility.
Closure Date:
9 We recommended that the server closet is maintained according to IT safety and security standards.
Closure Date:
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| 13-00026-185 | Community Based Outpatient Clinic Reviews at Manchester VA Medical Center, Manchester, NH | Comprehensive Healthcare Inspection Program | ||
1 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:
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| 12-03743-184 | Healthcare Inspection - Alleged Questionable Surgical Care in a VA Health Care System | Hotline Healthcare Inspection | ||
1 We recommended that the system Director ensure that the two alleged near misses are referred to quality management staff to determine if action should have been taken.
Closure Date:
2 We recommended that the system Director consult with Regional Counsel regarding possible clinical disclosure to the patient for whom quality of surgical technique concerns were identified.
Closure Date:
3 We recommended that the system Director ensure that initial focused professional practice evaluations are completed on all newly hired providers.
Closure Date:
4 We recommended that the system Director ensure that privileges are facility and provider specific for all providers.
Closure Date:
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| 13-01744-187 | Combined Assessment Program Summary Report – Evaluation of Nurse Staffing in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that all facilities fully implement the staffing methodology and complete all required steps.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that facilities improve processes to use the available data to manage and provide safe, cost-effective staffing.
Closure Date:
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| 13-01742-188 | Combined Assessment Program Summary Report – Evaluation of Mental Health Treatment Continuity at Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that facilities take action to improve post-discharge follow-up for MH patients, particularly those who were identified as high risk for suicide.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that clinicians consistently follow the required processes for patients who fail to report for scheduled MH appointments and document actions taken.
Closure Date:
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| 12-03885-168 | Insepction of VA Regional Office Boise, Idaho | Review | ||
1 We recommend the Boise VA Regional Office Director develop and implement a plan to ensure staff include recommendations for identified problems in their Systematic Analyses of Operations.
Closure Date:
2 We recommend the Boise VA Regional Office Director develop and implement a plan to monitor the effectiveness of training and the local checklist to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans¿ entitlement to mental health treatment when previous decisions did not address this issue as required.
Closure Date:
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| 13-00026-177 | Community Based Outpatient Clinic Reviews at Robley Rex VA Medical Center, Louisville, KY | 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 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 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 FPPEs are initiated for all providers who request new privileges at the Scott County CBOC.
Closure Date:
6 We recommended that the facility ensure annual fire drills are completed at the Carroll County and Scott County CBOCs.
Closure Date:
7 We recommended that all identified EOC deficiencies at the Carroll County and Scott County CBOCs are tracked and trended until corrected.
Closure Date:
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| 12-01480-183 | Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2012 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN senior managers, ensures that facility directors and Patient Safety Officers sit on the high-level committees that review QM results.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that completed corrective actions related to protected peer review are reported to the PRC.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that FPPEs for newly hired licensed independent practitioners are initiated and completed and that results are reported to the MEC.
Closure Date:
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14917