Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00376-201 | Combined Assessment Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the results of FPPEs for newly hired LIPs are consistently reported to the ECOMS.
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 when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed.
Closure Date:
4 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services
Closure Date:
5 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient care equipment is consistently cleaned between patient use.
Closure Date:
7 We recommended that processes be strengthened to ensure that gloves in all sizes and gowns are available in the therapy clinic areas.
Closure Date:
8 We recommended that processes be strengthened to ensure that inspectors are sufficiently rotated in inspection assignments and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that inspectors do not participate in inspections beyond their 3-year appointment expiration date and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated nurse, social worker, and administrative support person and a 0.25 FTE psychologist or other MH provider.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
12 We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
Closure Date:
13 We recommended that unit 134-3Cs nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
14 We recommended that managers initiate protected PR for the identified patient and complete any recommended review actions.
Closure Date:
15 We recommended that processes be strengthened to ensure that routine construction site inspections are conducted by the required CSC members, include all required elements, and are documented.
Closure Date:
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| 13-00888-203 | Combined Assessment Program Review of the VA Southern Nevada Healthcare System, Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from PRs are consistently completed and reported to the PR Committee.
Closure Date:
2 We recommended that the facility monitor compliance with the recently implemented observation bed use policy.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
4 We recommended that managers initiate actions to address identified deficiencies in the PCC pharmacies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
5 We recommended that the facility develop instructions for inspecting automated dispensing machines that include all VHA requirements and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
Closure Date:
7 We recommended that processes be strengthened to ensure that the CS Coordinator only performs occasional inspections and that a sufficient number of CS inspectors are appointed to conduct the monthly inspections.
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 the facility fully implement the nurse staffing methodology.
Closure Date:
10 We recommended that managers initiate protected PR for the one identified patient and complete any recommended review actions.
Closure Date:
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| 13-00889-206 | Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each CPR episode.
Closure Date:
2 We recommended that the facility continue to monitor the EHR copy and paste function.
Closure Date:
3 We recommended that processes be strengthened to ensure that results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
4 We recommended that processes be strengthened to ensure that the blood usage and review process includes the number of transfusions and number reviewed for appropriateness, the results of proficiency testing, PRs when transfusions did not meet criteria, and results of inspections by government or private (peer) entities.
Closure Date:
5 We recommended that processes be strengthened to ensure that when data analyses indicate problems or opportunities for improvement, actions taken are consistently followed to resolution in utilization management, outcomes of resuscitation, and RAI/MDS quality reviews.
Closure Date:
6 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:
7 We recommended that processes be strengthened to ensure that Infection Control Committee actions are implemented to address high-risk areas and that committee minutes document those actions.
Closure Date:
8 We recommended that processes be strengthened to ensure that Infection Control Committee minutes consistently reflect analysis of surveillance activities.
Closure Date:
9 We recommended that processes be strengthened to ensure that floors, ventilation system outlets, and horizontal surfaces in patient care areas are clean and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that mattresses, pillows, geri-chairs, and treatment table mats are routinely inspected and that those with compromised surfaces are repaired or removed from service.
Closure Date:
11 We recommended that processes be strengthened to ensure that expired commercial supplies are removed from patient care areas.
Closure Date:
12 We recommended that processes be strengthened to ensure that women's health clinic exit signage is properly oriented and visible from all hallways.
Closure Date:
13 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
14 We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education be documented.
Closure Date:
15 We recommended that processes be strengthened to ensure that the Home Respiratory Care Committee evaluates patient safety-related events for home oxygen patients and planning for patients discontinued from home oxygen therapy to determine whether additional actions are warranted.
Closure Date:
16 We recommended that all members of unit 4H/4J's expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
17 We recommended that managers complete protected PR for the identified patient and any recommended review actions.
18 We recommended that processes be strengthened to ensure that the Construction Safety Committee oversees construction and renovation activities, that the policy outlining the responsibilities of the committee is followed, that the multidisciplinary team conducts site visits at the specified frequency, and that meeting minutes contain discussion of site conditions and any required follow-up.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
20 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
Closure Date:
21 We recommended that processes be strengthened to ensure that designated employees receive initial and/or refresher construction safety training and that compliance be monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that ED staff document discharge instructions and evaluate patient and/or caregiver understanding of the discharge instructions.
Closure Date:
23 We recommended that processes be strengthened to ensure that the process for requesting and granting ED staff privileges complies with VHA policy.
Closure Date:
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| 13-00378-202 | Combined Assessment Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia | 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 data about observation bed use is gathered.
Closure Date:
3 We recommended that the all fire extinguishers have signage in accordance with National Fire Protection Association standards.
Closure Date:
4 We recommended that processes be strengthened to ensure that construction workers remove cardboard boxes in the outpatient pharmacy promptly or store them off the floor.
Closure Date:
5 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
6 We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
7 We recommended that the facility implement the mandated staffing methodology for nursing personnel.
Closure Date:
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| 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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15039