Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-04525-170 | Inspection of VA Regional Office Denver, Colorado | Review | ||
1 We recommend the Denver VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
Closure Date:
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| 13-00026-176 | Community Based Outpatient Clinic Reviews at Central Arkansas Veterans Healthcare System, Little Rock, AR, and G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS | 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:
2 We recommended that managers ensure that cervical cancer screening results are documented in the patient's EHR.
Closure Date:
3 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:
4 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
5 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
6 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
7 We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Russellville and Searcy CBOCs.
Closure Date:
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| 13-00994-180 | Healthcare Inspection - Legionnaires’ Disease at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Hotline Healthcare Inspection | ||
1 We recommended that the VA Pittsburgh Healthcare System Director ensure that any disinfectant system in use for Legionella prevention is monitored and maintained in accordance with manufacturer’s instructions.
Closure Date:
2 We recommended that the VA Pittsburgh Healthcare System Director ensure routine flushing of hot-water faucets and showerheads.
Closure Date:
3 We recommended that the VA Pittsburgh Healthcare System Director ensure close coordination between the Infection Prevention Team and Facilities Management Service staff.
Closure Date:
4 We recommended that the VA Pittsburgh Healthcare System Director ensure that when environmental cultures are positive, actions taken comply with Veterans Health Administration guidelines.
Closure Date:
5 We recommended that the VA Pittsburgh Healthcare System Director ensure that all healthcare-associated pneumonia patients are tested for Legionella infection.
Closure Date:
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| 12-03853-172 | Community Based Outpatient Clinic Reviews at Battle Creek VA Medical Center, Battle Creek, MI, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL | Comprehensive Healthcare Inspection Program | ||
1 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:
2 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:
3 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 time frame and that notification is documented in the EHR.
Closure Date:
4 We recommended that managers ensure clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
5 We recommended that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
6 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
7 We recommended that the Medical Executive Committee grants privileges consistent with the services provided at the Grand Rapids and Lansing CBOCs.
Closure Date:
8 We recommended that the Executive Committee of the Medical Staff grants privileges that are consistent with the services provided at the Evanston and McHenry CBOCs.
Closure Date:
9 We recommended that managers improve restroom access for disabled veterans at the Lansing CBOC.
Closure Date:
10 We recommended that managers maintain a clean and functioning environment of care at the Lansing CBOC.
Closure Date:
11 We recommended that managers clearly identify the location of fire extinguishers with appropriate signage at the Lansing CBOC.
Closure Date:
12 We recommended that managers implement a system to maintain auditory privacy during the check-in process at the Lansing CBOC.
Closure Date:
13 We recommended that staff secure PII on laboratory specimens during transport from the Lansing CBOC to the parent facility.
Closure Date:
14 We recommended that staff secure PII on laboratory specimens during transport from the Evanston and McHenry CBOCs to the parent facility.
Closure Date:
15 We recommended that the IT server closet at the McHenry CBOC is maintained according to IT safety and security standards.
Closure Date:
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| 12-02955-178 | Healthcare Inspection – Patient Care Issues and Contract Mental Health Program Mismanagement, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health take note and rectify the deficiencies described in this report with respect to the provision of quality mental health care and contract management, with the goal that veterans receive the highest quality medical care from either the VA or its partners.
Closure Date:
2 We recommended that the Facility Director evaluate the care of patients discussed in this report with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patients.
Closure Date:
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| 12-03869-179 | Healthcare Inspection - Mismanagement of Inpatient Mental Health Care, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health develops national policies that address contraband, visitation, urine drug screens, and escort services for inpatient mental health units.
Closure Date:
2 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit develops and implements policies that adequately address contraband, visitation, urine drug screening, and escort service.
Closure Date:
3 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit employs safeguards for documentation that accurately reflect staff observation of patients.
Closure Date:
4 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit strengthens program oversight including follow-up actions taken by leadership in response to patient incidents.
Closure Date:
5 We recommended that the VISN and Facility Directors ensure that the facility strengthen and improve the RCA process to ensure that all information and documentation related to the event are reviewed and that follow up actions are completed and timely.
Closure Date:
6 We recommended that the VISN and Facility Directors ensure that the facility improves communication with staff regarding debriefings and planned actions to address identified deficiencies.
Closure Date:
7 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health units are equipped with functional and well-maintained life support equipment.
Closure Date:
8 We recommended that the VISN and Facility Directors ensure that the facility evaluates the care of the subject patient with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patient.
Closure Date:
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| 12-04524-171 | -Interim Report - Participation in VBA's Veterans Retraining Assistance Program | Audit | ||
1 We recommend the Under Secretary for Benefits continue to issue certificates of eligibility until either 99,000 veterans have enrolled in an approved training program or until October 1, 2013, whichever occurs first.
Closure Date:
2 We recommend the Under Secretary for Benefits revise the Veterans Retraining Assistance Program certificate of eligibility letter to inform veterans that Veterans Benefits Administration will only pay benefits to a limited number of veterans.
Closure Date:
3 We recommend the Under Secretary for Benefits contact the veterans currently holding a certificate of eligibility, who have not yet enrolled in the approved training, and inform them that VBA will pay benefits only to a limited number of veterans. Inform the veterans they will need to check the VRAP Web site or contact VBA to confirm benefits are still available before enrolling in an approved training program.
Closure Date:
4 We recommend the Under Secretary for Benefits provide retroactive benefits to VRAP participants (not to exceed the FY 2012 authorization) who were enrolled in an approved training program in FY 2012, but did not receive benefits before October 1, 2012.
Closure Date:
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| 13-00431-173 | Combined Assessment Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that CS inspectors consistently perform and document reconciliation of 1 day's dispensing from the pharmacy to each automated unit and that compliance be monitored.
Closure Date:
2 We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
Closure Date:
3 We recommended that processes be strengthened to ensure that exit signs identifying alternate routes for egress are posted within construction sites.
Closure Date:
4 We recommended that processes be strengthened to ensure that sprinkler head paint protectors are removed as soon as possible and that in the event the protectors remain on in unattended areas for longer than 4 hours in a 24-hour period, a fire watch be implemented.
Closure Date:
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| 13-00374-174 | Combined Assessment Program Review of the Manchester VA Medical Center, Manchester, New Hampshire | 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 FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the Professional Standards Board.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Code Committee reviews each code episode.
Closure Date:
4 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed.
Closure Date:
5 We recommended that managers initiate actions to address the one identified physical security deficiency and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
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 the PCCT includes a dedicated psychologist and administrative support person.
Closure Date:
8 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
9 We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the CPRS.
Closure Date:
10 We recommended that processes be strengthened to ensure that the Chief of Staff reviews HRCP activities at least quarterly.
Closure Date:
11 We recommended that processes be strengthened to ensure that construction safety and infection surveillance activities related to construction projects are initiated at the same time as the projects and documented in the minutes of each committee.
Closure Date:
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| 12-04179-167 | Inspection of VA Regional Office Baltimore, Maryland | Review | ||
1 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure staff review all existing reminder notifications and schedule medical reexaminations as required.
Closure Date:
2 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure that for the future, staff routinely review reminder notifications and timely schedule medical reexaminations as required.
Closure Date:
3 We recommended the Baltimore VA Regional Office Director conduct a review of the 478 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
4 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure compliance with the Veterans Benefits Administration’s second signature requirements for traumatic brain injury claims.
Closure Date:
5 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure staff timely address all required elements of Systematic Analyses of Operations.
Closure Date:
6 We recommended the Baltimore VA Regional Office Director develop and implement a plan outlining how Veterans Service Center staff will accomplish all required homeless veterans outreach services, including creating a resource directory and regularly contacting homeless shelters and service providers.
Closure Date:
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14917