Recommendations
2106
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01189-267 | Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
Closure Date:
2 We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
Closure Date:
3 We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
Closure Date:
4 We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Closure Date:
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| 13-00696-254 | Healthcare Inspection - Follow-Up Assessment of Radiation Therapy, VA Long Beach Healthcare System, Long Beach, California | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health ensure that repeated deficiencies in the documentation of patient care are addressed and do not persist.
Closure Date:
2 We recommended that the VISN Director ensure that complications of radiation therapy that are managed at referring facilities are reported to the facility where radiation therapy was provided.
Closure Date:
3 We recommended that the VISN Director require that the facility Director ensure that radiation therapists adhere to local policy when shifts in the field of delivered radiation occur.
Closure Date:
4 We recommended that the VISN Director require that the facility Director ensure that adverse events in the Radiation Oncology department are consistently reported to facility managers as specified in the facility’s action plan in response to the 2011 OIG report.
Closure Date:
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| 13-00368-244 | Inspection of VA Regional Office Waco, Texas | Review | ||
1 We recommend the Waco VA Regional Office Director conduct a review of the 795 temporary 100 percent disability evaluations remaining from the data we used to perform the inspection and take appropriate action.
Closure Date:
2 We recommend the Waco VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of the training.
Closure Date:
3 We recommend the Waco VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration policy requiring second-signature review of each traumatic brain injury claim processed.
Closure Date:
4 We recommend that the Waco VA Regional Office Director develop and implement a plan to ensure staff follow Veterans Benefits Administration policy in including recommendations for identified problems in their Systematic Analyses of Operations.
Closure Date:
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| 13-01988-253 | Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the System Director consult with Regional Counsel to determine if a disclosure of the events related to the patient's episode of acute renal failure, as discussed in this report, is indicated.
Closure Date:
2 We recommended that the System Director ensure that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.
Closure Date:
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| 13-00709-257 | Inspection of VA Regional Office Jackson, Mississippi | Review | ||
1 We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and schedule medical reexaminations as required.
Closure Date:
2 We recommend the Jackson VA Regional Office Director develop and implement a plan to review the 195 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration and local second-signature requirements for traumatic brain injury claims.
Closure Date:
4 We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers within the VA Regional Office's jurisdiction.
Closure Date:
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| 13-00026-258 | Community Based Outpatient Clinic Reviews at Hunter Holmes McGuire VA Medical Center, Richmond, VA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that the PSB submits actions and recommendations for privileging and reprivileging to the MPSC and that meeting minutes reflect documents reviewed and the rationale for privileging or reprivileging at the Charlottesville and Emporia CBOCs.
Closure Date:
4 We recommended that managers minimize risks associated with the handling, storing, and disposing of hazardous materials in the hazardous waste storage room at the Charlottesville CBOC.
Closure Date:
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| 13-01674-256 | Combined Assessment Program Review of the Sioux Falls VA Health Care System, Sioux Falls, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scale scores upon change in condition and/or at discharge and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that acute care staff revise interprofessional treatment plans when there are risk level changes and that compliance be monitored.
Closure Date:
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| 13-01672-260 | Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
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 a process be established to track HPC consults that are not acted upon within 4 days of the request.
Closure Date:
4 We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
Closure Date:
5 We recommended that processes be strengthened to ensure that HPC inpatients pain is consistently reassessed and that results are documented timely in EHRs.
Closure Date:
6 We recommended that processes be strengthened to ensure that monthly DCHV Program and SA domiciliary self-inspection documentation includes all required elements.
Closure Date:
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| 13-00026-259 | Community Based Outpatient Clinic Review at Jack C. Montgomery VA Medical Center, Muskogee, OK | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of abnormal 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 the results within the required timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
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| 13-00026-252 | Community Based Outpatient Clinic Reviews at Amarillo VA Health Care System, Amarillo, TX and Northern Arizona VA Health Care System, Prescott, AZ | 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 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 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:
4 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
5 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
6 We recommended that managers ensure that clinicians administer tetanus vaccines when indicated.
Closure Date:
7 We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
Closure Date:
8 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
9 We recommended that the PSB grants privileges consistent with the services provided at the Lubbock CBOC.
Closure Date:
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15200