Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03851-102 | Community Based Outpatient Clinic Reviews at John J. Pershing VA Medical Center, Poplar Bluff, MO | 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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| 12-03854-114 | Community Based Outpatient Clinic Reviews at Iowa City VA Health Care System, Iowa City, IA | 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 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:
4 We recommended that the FPPE review for the Cedar Rapids CBOC providers is included in the Clinical Executive Board meeting minutes.
Closure Date:
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| 12-03852-109 | Community Based Outpatient Clinic Reviews at Spokane VA Medical Center, Spokane, WA | 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 the parent Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
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 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 at the Coeur d'Alene and Wenatchee CBOCs.
Closure Date:
6 We recommended that fire and life safety inspections are conducted annually at the Coeur d'Alene and Wenatchee CBOCs.
Closure Date:
7 We recommended that the Chief of OI&T evaluates the use of the IT closet and implements required measures at the Coeur d'Alene CBOC.
Closure Date:
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| 12-03852-110 | Community Based Outpatient Clinic Reviews at Alaska VA Healthcare System, Anchorage, AK | 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 fire and life safety inspections are conducted annually at the Kenai and Mat-Su CBOCs.
Closure Date:
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| 12-03850-112 | Community Based Outpatient Clinic Reviews at Charles George VA Medical Center, Asheville, NC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
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| 12-03850-106 | Community Based Outpatient Clinic Reviews at Salem VA Medical Center, Salem, VA | 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 document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that the Credentials Committee of the Executive Board for Clinical Affairs grants privileges consistent with the services provided at the Lynchburg and Wytheville CBOCs.
Closure Date:
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| 12-01556-108 | Healthcare Inspection – Alleged Quality of Care Issues and Communication Lapses, Washington DC VA Medical Center, Washington, DC | Hotline Healthcare Inspection | ||
1 We recommended that the Medical Center Director consult with Regional Counsel regarding possible institutional disclosure to the patient's family for whom quality of care concerns were identified.
Closure Date:
2 We recommended that the Medical Center Director take action to improve oversight of PA practice activities in the urology clinic.
Closure Date:
3 We recommended that the Medical Center Director conduct a peer review of the care identified in this report.
Closure Date:
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| 12-04605-107 | Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are reported timely 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 actions implemented to address high-risk areas are documented in Infection Control Committee minutes.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened.
Closure Date:
6 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:
7 We recommended that unit 4C North's expert panel and CLC unit First Floor's expert panel reassess the inpatient staffing needed following the required processes.
Closure Date:
8 We recommended that the annual staffing plan reassessment process ensure that the facility expert panel includes all required members.
Closure Date:
9 We recommended that managers initiate a protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
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| 12-02223-98 | Audit of NCA's Internal Gravesite Review of Headstone and Marker Placement | Audit | ||
1 We recommended the Under Secretary for Memorial Affairs ensure implementation of the three recommendations in the July 5, 2012, Management Advisory Memorandum.
Closure Date:
2 We recommended the Under Secretary for Memorial Affairs ensure management take corrective actions regarding the additional 153 errors identified in this report, including the notification of congressional committees and contacting families when possible.
Closure Date:
3 We recommended the Under Secretary for Memorial Affairs implement procedures to assess cemetery size and cemetery director responsibility to ensure adequate time and resources are available before conducting future gravesite reviews.
Closure Date:
4 We recommended the Under Secretary for Memorial Affairs implement controls, including a certification, to ensure gravesite layout maps are routinely updated, accurate, and provided to the cemeteries.
Closure Date:
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| 11-00336-292 | Audit of VHA's Beneficiary Travel Program | Audit | ||
1 We recommend the Under Secretary for Health develop mechanisms to ensure that approved Beneficiary Travel Program reimbursement data are reconciled with payment data.
Closure Date:
2 We recommend the Under Secretary for Health implement training necessary to ensure the Veterans Health Administration staff properly code Beneficiary Travel Program expenses entered into the Financial Management System.
Closure Date:
3 We recommend the Under Secretary for Health establish procedures to mitigate the risk of making duplicate payments on approved travel reimbursements.
Closure Date:
4 We recommend the Under Secretary for Health implement procedures to verify the accuracy of beneficiary addresses at the time of request for beneficiary travel.
Closure Date:
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14917