Recommendations
2106
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01123-249 | Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director ensure that the patient (case 1) endof-life care undergoes a quality review.
Closure Date:
2 We recommended that the facility Director ensure that CLC staff are appropriately trained and competent to care for all CLC residents, regardless of the residents' special care needs.
Closure Date:
3 We recommended that the facility Director conduct a risk assessment of the electronic monitoring system and implement improvements, as indicated.
Closure Date:
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| 13-00026-251 | Community Based Outpatient Clinic Reviews at Edward Hines, Jr. VA Hospital, Hines, IL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal and 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 and abnormal cervical cancer screening results are notified within the required 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 all specified medical equipment receive PM according to local policy at the Kankakee CBOC.
Closure Date:
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| 13-00026-248 | Community Based Outpatient Clinic Reviews at VA Butler Healthcare, Butler, PA | 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 signage is installed to direct physically challenged patients to the handicapped accessible entrance of the Armstrong County CBOC.
Closure Date:
5 We recommended that managers ensure all exit routes be clearly identified at the Armstrong County CBOC.
Closure Date:
6 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Armstrong County CBOC to the contracted processing facility.
Closure Date:
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| 13-01971-245 | Combined Assessment Program Review of the James A. Haley Veterans’ Hospital, Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that all services are included in the review of EHR quality.
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 processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the MH units, corrective actions taken, and tracking of corrective actions to closure.
Closure Date:
4 We recommended that processes be strengthened to ensure that sterile storage rooms are secured at all times and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that staff competency validation results and results of compliance with RME SOPs are reported to the Clinical Executive Board.
Closure Date:
7 We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities have initial training and annual competency validation documented.
Closure Date:
8 We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization have initial training and annual competency validation documented.
Closure Date:
9 We recommended that processes be strengthened to ensure that the SPS eyewash station is checked weekly and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the SPS decontamination area is clean.
Closure Date:
11 We recommended that processes be strengthened to ensure that monthly CS findings summaries and quarterly trend reports are provided to the facility Director consistently and timely.
Closure Date:
12 We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that IC and tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
14 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
Closure Date:
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| 13-00897-242 | Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York | 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 initiated.
Closure Date:
3 We recommended that the local observation bed policy be revised to include all required elements and that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
4 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
Closure Date:
5 We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
6 We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
7 We recommended that processes be strengthened to ensure that the blood usage and review process includes the number of units that were outdated or otherwise discarded, the results of proficiency testing, and the results of inspections by government or private (peer) entities.
Closure Date:
8 We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled; that hard copy orders for 5 randomly selected dispensing activities are validated in all non-pharmacy CS areas; and that at the Batavia pharmacy, audit trails for destruction of 10 randomly selected drugs are consistently verified.
Closure Date:
9 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
Closure Date:
10 We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
11 We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff are consistent in pressure ulcer documentation of location, stage, size, characteristics, risk scale score, and date acquired and whether the wound has improved or deteriorated during the admission or at the time of discharge.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff consistently perform and document daily skin inspections and/or daily risk scales.
Closure Date:
14 We recommended that processes be strengthened to ensure that pressure ulcer education is provided to patients at risk for or with pressure ulcers and/or their caregivers.
Closure Date:
15 We recommended that processes be strengthened to ensure that designated employees receive training on how to accurately document pressure ulcer findings and that compliance be monitored.
Closure Date:
16 We recommended that nurse managers monitor the staffing methodology that was implemented in December 2012.
Closure Date:
17 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
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| 13-00026-233 | Community Based Outpatient Clinic Reviews at Jesse Brown VA Medical Center, Chicago, IL | 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 allotted timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that patients with abnormal 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 tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging providers at the Chicago Heights and Lakeside CBOCs.
Closure Date:
6 We recommended that the MEC grants privileges consistent with the services provided at the Chicago Heights and Lakeside CBOCs.
Closure Date:
7 We recommended that managers ensure that MSDS are readily available to staff at the Lakeside CBOC.
Closure Date:
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| 13-00586-228 | Inspection of VA Regional Office San Juan, Puerto Rico | Review | ||
1 We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries to the electronic record as required.
Closure Date:
2 We recommend the San Juan VA Regional Office Director develop and implement a plan to review for accuracy the 132 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure effective second-signature reviews of traumatic brain injury claims decisions.
Closure Date:
4 We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure staff completely and timely address all required elements of Systematic Analyses of Operations.
Closure Date:
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| 13-00896-234 | Combined Assessment Program Review of the VA Maryland Health Care System, Baltimore, Maryland | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the Medical Executive 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 data about observation bed use is gathered.
Closure Date:
4 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the events.
Closure Date:
5 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
6 We recommended that the quality control policy for scanning includes linking the scanned documents to the correct record.
Closure Date:
7 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
8 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
Closure Date:
9 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:
10 We recommended that processes be strengthened to ensure that oxygen tanks are properly secured and stored in a manner that distinguishes between empty and full tanks.
Closure Date:
11 We recommended that processes be strengthened to ensure that soiled utility rooms are secured at all times.
Closure Date:
12 We recommended that processes be strengthened to ensure that EOC rounds are consistently conducted in the Annex building in accordance with VHA and local policy.
Closure Date:
13 We recommended that facility policy be amended to include that CS Coordinators must have complete understanding of CS policies and the VHA inspection process and to include requirements for new CS inspector orientation and/or annual training thereafter.
Closure Date:
14 We recommended that the instructions for inspecting automated dispensing machines be amended to include monthly CS inspector reconciliation of 1 day's dispensing activity and that compliance be monitored.
Closure Date:
15 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:
16 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:
17 We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
18 We recommended that the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that acute care staff consistently provide and document completion of recommended PU interventions and that compliance be monitored.
Closure Date:
20 We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
Closure Date:
21 We recommended that the facility establish staff PU education requirements and that compliance be monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection and that compliance be monitored.
Closure Date:
23 We recommended that nursing managers ensure compliance with all elements of the staffing methodology that was implemented in December 2012.
Closure Date:
24 We recommended that the facility ensure that the multidisciplinary committee responsible for construction and renovation oversight includes all required members.
Closure Date:
25 We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
26 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
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| 13-01673-240 | Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are reported timely to the MEC.
Closure Date:
2 We recommended that processes be strengthened to ensure that inpatient bathrooms are clean and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service.
Closure Date:
4 We recommended that processes on the acute MH inpatient units be strengthened to ensure that nurses' stations and medication rooms are secured from unauthorized entry and that furniture meets safety requirements.
Closure Date:
5 We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive annual competency assessments.
Closure Date:
6 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
7 We recommended that the facility ensure the multidisciplinary committee responsible for construction and renovation oversight includes all required members.
Closure Date:
8 We recommended that processes be strengthened to ensure that construction site inspection documentation includes all the required elements.
Closure Date:
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| 12-04456-232 | Inspection of VA Regional Office Roanoke, Virginia | Review | ||
1 We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record as required.
Closure Date:
2 We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure claims processing staff timely schedule medical reexaminations when the reminder notifications are received.
Closure Date:
3 We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits.
Closure Date:
4 We recommend the Roanoke VA Regional Office Director develop and implement a plan to review for accuracy the 709 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
Closure Date:
5 We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure effective second signature reviews of traumatic brain injury claims decisions.
Closure Date:
6 We recommend the Roanoke 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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15200