Recommendations
2106
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00886-210 | Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey | 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 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 clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
4 We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes and that code sheets are scanned into the EHRs.
Closure Date:
5 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
Closure Date:
6 We recommended that processes be strengthened to ensure that sensitive patient information is secured on computer screens in the ED.
Closure Date:
7 We recommended that processes be strengthened to ensure that medical equipment in the ED is terminally cleaned after patient discharge.
Closure Date:
8 We recommended that processes be strengthened to ensure that supplies and equipment in the East Orange PT clinic are properly stored.
Closure Date:
9 We recommended that facility policy be amended to address that the CS Coordinator PD or functional statement must include CS inspection and coordination, to include that the CS Coordinator must have complete understanding of CS policies and VHA inspection process, and to include requirements for new CS inspector orientation and annual training thereafter.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
12 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
13 We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
Closure Date:
14 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
15 We recommended that processes be strengthened to ensure that home oxygen program patients deemed to be high risk have fire risk assessments completed and that 3-month follow-up evaluations are completed for all home oxygen program patients.
Closure Date:
16 We recommended that unit 9A's expert panel include all required members.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
18 We recommended that managers initiate protected peer review for the identified patient and complete any recommended review actions.
Closure Date:
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| 13-00026-213 | Community Based Outpatient Clinic Reviews at Central Texas Veterans Health Care System, Temple, TX, and VA Texas Valley Coastal Bend Health Care System, Harlingen, TX | 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.
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.
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
5 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
6 We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
7 We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Cedar Park CBOC.
8 We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Corpus Christi Satellite, Harlingen OPC, and Laredo CBOC.
9 We recommended that signage is installed at the Corpus Christi Satellite, Harlingen OPC, and McAllen Satellite to clearly identify the location of fire extinguishers.
10 We recommended that a panic alarm system is installed at the Laredo CBOC.
11 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispen
12 We recommended that the placement of the telecommunications network beevaluated and that appropriate safety measures are implemented at theCorpus Christi Satellite.
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| 13-00432-217 | Combined Assessment Program Review of the Spokane VA Medical Center, Spokane, Washington | 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 CACC reviews each code episode.
Closure Date:
3 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person and a dedicated psychologist or other mental health provider.
Closure Date:
4 We recommended that the PCCT provide end-of-life training on a regular basis.
Closure Date:
5 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
6 We recommended that processes be strengthened to ensure that HPC consults are acted upon within 7 days of the request.
Closure Date:
7 We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed within 4 hours following an intervention and results documented in the EHR and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that pain interventions identified on HPC inpatients' IPCs are consistently implemented.
Closure Date:
9 We recommended that processes be strengthened to ensure that IPCs specify responsible team members.
Closure Date:
10 We recommended that processes be strengthened to ensure that the CLC social worker documents in the EHR that the CLC condolence letter was sent.
Closure Date:
11 We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
Closure Date:
12 We recommended that the facility establish an HRCT.
Closure Date:
13 We recommended that the facility conduct periodic, unscheduled onsite visits to the oxygen delivery contractor.
Closure Date:
14 We recommended that processes be strengthened to ensure that home oxygen program patients have active prescriptions and that patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
15 We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
Closure Date:
16 We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
Closure Date:
18 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
19 We recommended that nursing managers monitor the staffing methodology that was implemented in August 2011.
Closure Date:
20 We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
Closure Date:
21 We recommended that processes be strengthened to ensure that documentation of construction site inspections includes all required elements.
Closure Date:
22 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in ICC minutes.
Closure Date:
23 We recommended that processes be strengthened to ensure that CSC minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
Closure Date:
24 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
25 We recommended that processes be strengthened to ensure that when required, continuous negative air pressure is achieved prior to initiating work at a construction site.
Closure Date:
26 We recommended that processes be strengthened to ensure that physician orders and discharge summaries are consistent.
Closure Date:
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| 13-01741-215 | Combined Assessment Program Summary Report - Evaluation of Colorectal Cancer Screening and Follow-Up in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Closure Date:
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| 12-04328-211 | Inspection of VA Regional Office Wilmington, Deleware | Review | ||
1 We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and timely schedule medical reexaminations when the reminder notifications generate.
Closure Date:
2 We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits when appropriate.
Closure Date:
3 We recommend the Wilmington VA Regional Office Director conduct a review of the 57 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
4 We recommend the Wilmington 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 under the VA Regional Office's jurisdiction.
Closure Date:
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| 13-00026-212 | Community Based Outpatient Clinic Reviews at Oklahoma City VA Medical Center, Oklahoma City, OK | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are strengthened 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 processes are strengthened to 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 managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the PSB grants setting-specific clinical privileges for all providers at the Ardmore and Enid CBOCs.
Closure Date:
6 We recommended that handicapped parking spaces at the Enid CBOC meet ADA requirements for parking space identification.
Closure Date:
7 We recommended that restroom access is improved for disabled veterans at the Ardmore and Enid CBOCs.
Closure Date:
8 We recommended that laboratory specimens are secured during transport from the Ardmore and Enid CBOCs to the parent facility.
Closure Date:
9 We recommended that the IT server closets are maintained according to IT safety and security standards at the Ardmore and Enid CBOCs.
Closure Date:
10 We recommended that managers ensure that an AED is available at the Enid CBOC.
Closure Date:
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| 13-00026-207 | Community Based Outpatient Clinic Reviews at North Florida/South Georgia Veterans Health System, Gainesville, FL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that the MEC grants privileges consistent with the services provided at the Ocala CBOC.
Closure Date:
4 We recommended that fire drills are performed every 12 months at the Ocala CBOC.
Closure Date:
5 We recommended that patient privacy is maintained in the examination rooms at the Ocala and St. Marys CBOCs.
Closure Date:
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| 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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| 13-00889-206 | 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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15200