Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 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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15039