Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
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6 We recommended that processes be strengthened to ensure that patient care areas, public stairways, and restrooms are clean.
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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.
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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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| 12-03355-88 | Inspection of the VA Regional Office, Detroit, Michigan | Review | ||
1 We recommend the Detroit VA Regional Office Director provide training and implement controls to ensure staff follow current Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
Closure Date:
2 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims rating decisions.
Closure Date:
3 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure Veterans Service Center staff follow Veterans Benefits Administration policy on proper establishment of dates of claim.
Closure Date:
4 We recommend the Detroit VA Regional Office Director amend the local Workload Management Plan to include specific requirements for management oversight and review to improve claims processing timeliness.
Closure Date:
5 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations.
Closure Date:
6 We recommend the Detroit 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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| 11-04359-80 | Review of VHA's South Texas Veterans Health Care System's Management of Fee Care Funds | Audit | ||
1 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for clinical and fee staff to properly process authorizations for fee care.
Closure Date:
2 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for fee staff to process payments of vendor invoices timely.
Closure Date:
3 We recommended the Director of the South Texas Veterans Health Care System ensure clinical and fee staff receive periodic training on fee care procedures.
Closure Date:
4 We recommended the Director of the South Texas Veterans Health Care System establish independent oversight mechanisms, such as periodic audits or reviews by the Compliance Officer, to ensure that newly established procedures at the South Texas Veterans Health Care System are followed to properly control and manage funds for its fee care program.
Closure Date:
5 We recommended the Director of the Veterans Integrated Service Network establish independent oversight mechanisms, such as periodic audits or reviews, to ensure that procedures for properly controlling and managing fee care program funds are followed at the South Texas Veterans Health Care System.
Closure Date:
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| 12-03744-84 | Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas | 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 Staff Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
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 processes be strengthened to ensure that patient care areas are clean and well maintained and clean and dirty supplies are stored separately and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service and that the facility be well maintained.
Closure Date:
6 We recommended that processes be strengthened to ensure that damaged therapy mats in the Temple division physical therapy clinic are repaired or removed from service.
Closure Date:
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated MH provider and an administrative support person.
Closure Date:
9 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
10 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:
11 We recommended that managers initiate a protected peer review for the three identified patients and complete any recommended review actions.
Closure Date:
12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
Closure Date:
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| 12-04214-83 | Healthcare Inspection – Emergency Department Evaluation of a Homeless Veteran VA North Texas Health Care System, Dallas, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the facility develops a written SOP for emergency department patient flow and orientation is provided to all emergency department staff and on-call personnel.
Closure Date:
2 We recommended that the Facility Director ensure that EDIS is used as required.
Closure Date:
3 We recommended that the Facility Director ensure that SW services are provided in the emergency department as required.
Closure Date:
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| 12-02602-79 | Combined Assessment Program Review of the Huntington VA Medical Center,Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that PR analysis summary reports be discussed quarterly at the ECMS and that the discussion be documented in meeting minutes.
Closure Date:
2 We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the ECMS.
Closure Date:
3 We recommended that the facility develop a local policy mandating a Cardiopulmonary Resuscitation Committee.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
Closure Date:
6 We recommended that processes be strengthened to ensure that smoking occurs in designated areas only.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff are able to locate MSDS for hazardous chemicals used in their areas.
Closure Date:
8 We recommended that the annual staffing plan reassessment process ensures that each unit has a unit-based expert panel and that each panel includes members from all nursing roles.
Closure Date:
9 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
Closure Date:
10 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
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| 12-03740-75 | Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina | 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 processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
Closure Date:
4 We recommended that the quality control policy for scanning be revised to include image quality, linking of scanned documents to the correct record, and indexing the documents.
Closure Date:
5 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
6 We recommended that processes be strengthened to ensure that required members from surgery and medicine attend Transfusion Committee meetings.
Closure Date:
7 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
8 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
9 We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results for all projects are documented.
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10 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of deficiencies and follow-up actions in response to unsafe conditions identified during inspections.
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11 We recommended that processes be strengthened to ensure that Material Safety Data Sheets for chemicals used in construction sites are located within the construction areas.
Closure Date:
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15039