Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03850-105 | Community Based Outpatient Clinic Reviews at Durham VA Medical Center, Durham, NC | 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 pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
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| 12-03745-93 | Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa | 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 results from FPPEs are consistently reported to the Medical Executive Committee.
Closure Date:
3 We recommended that processes be strengthened to ensure that conversions from observation bed status to acute admissions are consistently 30 percent or less.
Closure Date:
4 We recommended that the facility ensure compliance with VHA policy requiring an intraoperative x-ray for incorrect sharp counts.
Closure Date:
5 We recommended that processes be strengthened to ensure that CS quarterly trend reports are consistently provided to the facility Director.
Closure Date:
6 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated 0.25 FTE MH provider and that local policy be updated to reflect this requirement.
Closure Date:
8 We recommended that the facility establish a policy to reduce the fire hazards of smoking associated with oxygen treatment.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
10 We recommended that all members of the facility expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
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| 11-04376-81 | Review of VBA’s Transition to a Paperless Claims Processing Environment | Audit | ||
1 We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology broaden the types of claims tested at additional sites to provide assurance that the range of VBA functionality and processing requirements can be met through VBMS.
Closure Date:
2 We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology establish a plan with milestones to resolve the system issues to ensure system testing does not adversely impact and add to the existing claims processing backlog.
Closure Date:
3 We recommend the Under Secretary for Benefits ensure development of a detailed plan, including costs associated with the long-term scanning solution, so that transformation efforts do not adversely impact and add to the existing claims processing backlog.
Closure Date:
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| 12-02476-103 | Healthcare Inspection – Mid-Level Provider Oversight, George E. Wahlen VA Medical Center, Salt Lake City, UT | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director establish an equivalent process to Focused Professional Practice Evaluations and Ongoing Professional Practice Evaluations for mid-level scope of practice reviews.
Closure Date:
2 We recommended that the facility Director ensure that the mid-level Professional Standards Board forwards their recommendations for the granting of scopes of practice to the Medical Executive Committee for review.
Closure Date:
3 We recommended that all staff in the Intensive Care Unit, including the attending physicians, receive training on adverse event reporting.
Closure Date:
4 We recommended that systems be strengthened to ensure that all Intensive Care Unit near misses and adverse events are reported.
Closure Date:
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| 12-04192-97 | Combined Assessment Program Review of the San Francisco VA Medical Center, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the patient safety manager be included in the Leadership Board Committee.
Closure Date:
2 We recommended that data about observation bed use be gathered.
Closure Date:
3 We recommended that Emergency Medical Committee code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the code.
Closure Date:
4 We recommended that processes be strengthened to ensure that only sharps are disposed of in sharps containers.
Closure Date:
5 We recommended that processes be strengthened to ensure that Engineering conducts and documents initial safety inspections on non-patient equipment.
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 processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
8 We recommended that a process be established to ensure that HPC consults are acted upon within the timeframe required by local policy.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
10 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:
11 We recommended that processes be strengthened to ensure that competency assessments are completed for all staff authorized to perform oxygen testing.
Closure Date:
12 We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
Closure Date:
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| 12-04108-96 | Healthcare Inspection–Appointment Scheduling and Access Patient Call Center, VA San Diego Healthcare System, San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensures that Patient Call Center agents follow policy and procedures for scheduling follow-up appointments and managing non-urgent symptomatic calls.
Closure Date:
2 We recommended that the System Director ensures that timeframes for the primary care teams to follow-up with patients be established.
Closure Date:
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| 12-04189-95 | Combined Assessment Program Review of the Oklahoma City VA Medical Center,Oklahoma City, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers initiate actions to address the three identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
2 We recommended that processes be strengthened to ensure that monthly inspections of automatic dispensing machines are conducted in accordance with local policy.
Closure Date:
3 We recommended that processes be strengthened to ensure that monthly CS inspection findings summaries and quarterly trend reports are consistently provided to the facility Director.
Closure Date:
4 We recommended that the CS Coordinator's duties be included in the position description.
Closure Date:
5 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy areas with CS are conducted and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
8 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:
9 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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| 12-00710-85 | Combined Assessment Program Review of the VA New York Harbor Healthcare System,New York, New York | 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 the required intervals and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
4 We recommended that processes be strengthened to ensure that employees who perform glucose POCT receive training and have competency assessed annually.
Closure Date:
5 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient care areas, public stairways, and restrooms are clean.
Closure Date:
7 We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
Closure Date:
8 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections are conducted, that documentation includes all required elements, and that documentation reflects when deficiencies are resolved and that compliance be monitored.
Closure Date:
9 We recommended that managers take immediate steps to ensure the St. Albans domiciliary is in compliance with EOC standards for cleanliness, safety, and infection prevention and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the St. Albans domiciliary access point CCTV is functional at all times.
Closure Date:
11 We recommended that processes be strengthened to ensure that the Brooklyn MH RRTP residential environment provides privacy for veterans.
Closure Date:
12 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Closure Date:
13 We recommended that processes be strengthened to ensure that discharge instructions are completed for all discharged patients and that they address medications, diet, and the initial follow-up appointment.
Closure Date:
14 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers or required by local policy.
Closure Date:
15 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
Closure Date:
16 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
Closure Date:
17 We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
Closure Date:
18 We recommended that processes be strengthened to ensure that all patients in buprenorphine treatment undergo UDS with the frequency required by local policy.
Closure Date:
19 We recommended that the facility expert panel be convened prior to the next annual staffing plan reassessment and that the panel review all the unit-based expert panels' recommendations.
Closure Date:
20 We recommended that processes be strengthened to ensure that FPPEs are consistently initiated and that results are consistently reported to the PSB and documented in PSB meeting minutes.
Closure Date:
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| 11-00711-74 | Healthcare Inspection – Foot Care for Patients with Diabetes and Additional Risk Factors for Amputation | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.
Closure Date:
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| 12-04190-89 | Combined Assessment Program Review of the North Florida/South Georgia Veterans Health System, Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are 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 staff perform continuing stay reviews for at least 75 percent of acute care patients.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Emergency Effectiveness Committee reviews individual resuscitation events.
Closure Date:
6 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
7 We recommended that processes be strengthened to ensure that the blood usage review process includes the results of proficiency testing done by the laboratory.
Closure Date:
8 We recommended processes be strengthened to ensure that the PCCT includes a dedicated nurse and administrative support person.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
10 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
11 We recommended that processes be strengthened to ensure that all designated staff complete respirator fit testing.
Closure Date:
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14917