Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00277-134 | Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Board.
Closure Date:
2 We recommended that processes be strengthened to ensure that continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that the facility is well maintained and that compliance be monitored and that damaged furniture in patient care areas be repaired or removed from service.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated correctly when opened.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient privacy is maintained in the PM&R clinic during potentially exposing treatment modalities.
Closure Date:
7 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility and unit-based expert panel members.
Closure Date:
8 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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| 11-02585-129 | Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health ensure that VHA program officials provide additional guidance on what constitutes disruptive behavior and establish common terminology.
Closure Date:
2 We recommended that the Under Secretary for Health ensure that VHA program officials develop guidelines for what information VHA facilities should document regarding disruptive incidents and where this information should be documented.
Closure Date:
3 We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents.
Closure Date:
4 We recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents.
Closure Date:
5 We recommended that the Under Secretary for Health ensure that VHA facilities implement procedures to ensure more timely assignment of Category I PRFs.
Closure Date:
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| 12-04604-127 | Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Medical Emergency Committee collects data that measures performance in responding to resuscitation events and that code reviews include screening for clinical issues prior to codes that may have contributed to the occurrence of the codes.
Closure Date:
2 We recommended that the quality control policy for scanning includes the linking of scanned documents to the correct EHR and that processes be strengthened to ensure that the review of EHR quality includes all services and that EHR quality review reports are analyzed.
Closure Date:
3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicate problems or opportunities for improvement are evaluated for effectiveness in Geriatric and Extended Care Performance Improvement Council data and the Patient Flow Coordination Collaborative.
Closure Date:
4 We recommended that facility managers correct the identified cleanliness and environmental safety issues and that the EOC Committee documents progress in EOC Committee minutes.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and discarded when expired.
Closure Date:
6 We recommended that managers initiate actions to address the identified physical security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
7 We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is reconciled and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
Closure Date:
9 We recommended that the CS Coordinator's duties be included in his or her position description.
Closure Date:
10 We recommended that processes be strengthened to ensure that all CS inspectors are appointed in writing by the facility Director prior to assuming their duties.
Closure Date:
11 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates.
Closure Date:
12 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS include all required elements and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated physician and administrative support person.
Closure Date:
14 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
15 We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the Computerized Patient Record System.
Closure Date:
16 We recommended that processes be strengthened to ensure that patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensures that all required staff are members of the unit-based and facility expert panels.
Closure Date:
18 We recommended that 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 the facility complete the staffing methodology process.
Closure Date:
20 We recommended that the facility establish a construction safety program with a multidisciplinary committee that effectively monitors infection control, safety, and security issues during construction and renovation activities in accordance with VHA requirements.
Closure Date:
21 We recommended that all identified infection control, safety, and security deficiencies for the Building 7 construction project be corrected and that compliance be monitored. VA
Closure Date:
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| 12-02802-111 | Review of Alleged Transmission of Sensitive VA Data Over Internet Connections | Audit | ||
2 We recommend the Assistant Secretary for Information and Technology require that OIT personnel complete specialized training emphasizing the importance of encrypting sensitive VA data transmitted across public Internet connections.
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| 12-03077-122 | Combined Assessment Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up at least weekly during the first 30 days after discharge and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
Closure Date:
4 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
5 We recommended that processes be strengthened to ensure that interdisciplinary teams develop treatment plans for all polytrauma outpatients who need interdisciplinary care.
Closure Date:
6 We recommended that minimum polytrauma staffing levels be maintained.
Closure Date:
7 We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
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| 12-04191-123 | Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that
results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that
continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure that
code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the code.
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 clinicians perform and document patient assessments following blood product transfusions.
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 IC Committee minutes reflect follow-up on actions that were implemented to address identified problems.
Closure Date:
8 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
Closure Date:
9 We recommended that processes be strengthened to ensure that KT clinic staff consistently change linens and clean equipment between patient use.
Closure Date:
10 We recommended that the stained privacy curtains in the KT clinic be replaced and that privacy curtains be routinely inspected and replaced as needed.
Closure Date:
11 We recommended that processes be strengthened to ensure that medications in the PT clinic are secured at all times.
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 the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
15 We recommended that the facility expert panel review unit 34's and CLC unit 3's expert panels' recommendations.
Closure Date:
16 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:
17 We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
Closure Date:
18 We recommended that processes be strengthened to ensure that IC staff conduct contractor TB risk assessments prior to construction project initiation.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor TB skin test results are documented.
Closure Date:
20 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:
21 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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| 12-03854-115 | Community Based Outpatient Clinic Reviews at William S. Middleton Memorial Veterans Hospital, Madison, WI | 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 pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
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| 12-03753-121 | Healthcare Inspection – Issues at a VA Mid South Healthcare Network Dental Clinic | Hotline Healthcare Inspection | ||
1 We recommend that the System Director ensure that dental clinic staff have adequate knowledge regarding periodontal disease.
Closure Date:
2 We recommend that the System Director ensure treatment plans are developed, revised, followed, and documented.
Closure Date:
3 We recommend that the System Director develop and implement a plan to improve communication and professional interaction among dental clinic staff.
Closure Date:
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| 12-03851-117 | Community Based Outpatient Clinic Reviews at Marion VA Medical Center, Marion, IL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the parent Facility Director ensures that each CBOC is assigned a WH Liaison and that the WH Liaison collaborates with the Women Veterans Program Manager.
Closure Date:
2 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
3 We recommended that managers ensure that clinicians administer tetanus 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 service chiefs' documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Farmington and West Plains CBOCs.
Closure Date:
6 We recommended that the PSB grants LIPs setting-specific privileges that are consistent with the services provided at the Farmington and West Plains CBOCs.
Closure Date:
7 We recommended that signage is installed at the West Plains CBOC to clearly identify the location of fire extinguishers.
Closure Date:
8 We recommended that fire safety inspections are conducted annually at the West Plains CBOC.
Closure Date:
9 We recommended that processes are strengthened to ensure patient privacy is maintained during examination at the Farmington CBOC.
Closure Date:
10 We recommended that managers ensure that AEDs are checked daily at the West Plains CBOC, as required by facility policy.
Closure Date:
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| 12-03477-118 | Inspection of Veterans Service Center Cheyenne, Wyoming | Review | ||
1 We recommend the Denver VA Regional Office Director develop and implement controls to ensure Cheyenne Veterans Service Center staff timely schedule routine future medical reexaminations upon receipt of electronic system-generated reminder notifications.
Closure Date:
2 We recommend the Denver VA Regional Office Director develop and implement a Workload Management Plan that includes claims processing cycle time goals for the Cheyenne Veterans Service Center.
Closure Date:
3 We recommend the Denver VA Regional Office Director reinforce controls to ensure Cheyenne Veterans Service Center managers follow the Veterans Benefits Administration's policy and Workload Management Plan for all claims pending more than 1 year.
Closure Date:
4 We recommend the Denver VA Regional Office Director develop and implement a plan to ensure staff prioritize Systematic Analyses of Operations and corresponding recommendations and address all required elements using thorough analysis and relevant data.
Closure Date:
5 We recommend the Denver VA Regional Office Director develop and implement a plan to ensure Rating Veterans Service Representatives correctly address Gulf War veterans' entitlement to mental health treatment as required.
Closure Date:
6 We recommend the Denver VA Regional Office Director develop and implement a plan to monitor the effectiveness of training to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans' entitlement to mental health treatment when denying service connection for mental disorders.
Closure Date:
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14917