Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-00580-50 | Community Based Outpatient Clinic Reviews Franklin, WV; Stephens City, VA; Greenbelt, MD; Southeast Washington, DC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Franklin and Stephens City CBOC clinicians document education of foot care to diabetic patients in CPRS.
Closure Date:
2 We recommended that the Franklin and Stephens City CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
3 We recommended that the Southeast Washington CBOC clinicians document complete foot screenings for diabetic patients in CPRS.
Closure Date:
4 We recommended that the Greenbelt and Southeast Washington CBOC clinicians document education of foot care to diabetic patients in CPRS.
Closure Date:
5 We recommended that the Greenbelt and Southeast Washington CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
6 We recommended that the Stephens City CBOC establish a process to ensure that patients with normal mammograms are notified of results within the allotted timeframe and that notification is documented in the medical record.
Closure Date:
7 We recommended that the managers at the Greenbelt and Southeast Washington CBOCs ensure that all mammogram results are documented using the BI-RADS code categories.
Closure Date:
8 We recommended that the Women's Health Program Manager at the Washington DC VAMC ensure that the Greenbelt and Southeast Washington CBOC fee-basis mammography results are received and scanned into CPRS.
Closure Date:
9 We recommended that the Executive Committee of the Medical Staff, Credentialing Committee, grant privileges consistent with the services provided at the Franklin and Stephens City CBOCs.
Closure Date:
10 We recommended that the process is strengthened to ensure that privileges granted to psychologists are provider specific and consistent with the setting in which the services are provided at the Greenbelt CBOC.
Closure Date:
11 We recommended that privacy is maintained at all times during a patient physical examination at the Franklin CBOC.
Closure Date:
12 We recommended that signage is installed at the Franklin CBOC to clearly identify the location of fire extinguishers.
Closure Date:
13 We recommended that fire extinguishers are inspected at the Franklin CBOC and that maintenance and inspection dates are documented in accordance with NFPA Life Safety Code.
Closure Date:
14 We recommended that biohazardous waste containers are stored appropriately and that clean and dirty items are stored in separate locations at the Franklin CBOC.
Closure Date:
15 We recommended that the electrical closet is free of hazardous chemicals at the Stephens City CBOC.
Closure Date:
16 We recommended that fire drills and fire safety inspections are conducted annually at the Greenbelt CBOC.
Closure Date:
17 We recommended that the Facility Director determines, with the assistance of the Regional Counsel, the extent and collectability of the overpayments at the Franklin CBOC.
Closure Date:
18 We recommended that the Facility Director ensures that the contractor provide the invoice in the prescribed format at the Franklin CBOC.
Closure Date:
19 We recommended that the Facility Director ensures that all the performance-reporting provisions of the contract are completed and monitored at the Franklin CBOC.
Closure Date:
20 We recommended that the Facility Director considers adding controls in the invoice validation process, such as preparing a monthly billable roster with VA data at the Franklin CBOC.
Closure Date:
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| 12-03858-46 | Healthcare Inspection – Alleged Resident Abuse and Abuse Reporting Irregularities at the Pueblo Community Living Center, VA Eastern Colorado Healthcare System, Denver, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the system Director ensure all Associate Chiefs of Nursing and Community Living Center staff receive retraining on the requirements for reporting allegations of abuse.
Closure Date:
2 We recommended that the system Director ensures procedures to report, log, track, trend, and analyze injuries of unknown origin at the Community Living Center are developed.
Closure Date:
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| 12-02277-49 | Healthcare Inspection - Clinical and Administrative Allegations Involving Surgical Service, Carl Vinson VA Medical Center, Dublin, GA | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director ensure that provider reprivileging processes be conducted in accordance with VHA guidelines.
Closure Date:
2 We recommended that the facility Director ensure the OOPRC collects and analyzes aggregated surgical complication data to identify trends and patterns, and takes appropriate corrective actions when indicated.
Closure Date:
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| 12-00581-27 | Community Based Outpatient Clinic Reviews Minden (Carson Valley), NV; Auburn (Sierra Foothills), Chula Vista, and Escondido, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensure that foot screening and patient referral guidelines are established in accordance with VHA policy.
Closure Date:
2 We recommended that the Sierra Foothills CBOC clinicians document foot care education to diabetic patients in CPRS.
Closure Date:
3 We recommended that the Carson Valley CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
Closure Date:
4 We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
5 We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document that therapeutic footwear or orthotics is prescribed to diabetic patients identified at high risk for extremity ulcers and amputation.
Closure Date:
6 We recommended that the Chula Vista and Escondido CBOC clinicians document foot care education to diabetic patients in CPRS.
Closure Date:
7 We recommended that the Chula Vista and Escondido CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
Closure Date:
8 We recommended that the Chula Vista and Escondido CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
9 We recommended that the Carson Valley CBOC establish a process to ensure that patients with normal mammogram results are notified of results within the allotted timeframe and that notification is documented in the medical record.
Closure Date:
10 We recommended that the Women¿s Health Liaison at the Chula Vista CBOC attend the Women¿s Health Committee meetings and routinely collaborate with the Women Veterans Program Manager.
Closure Date:
11 We recommended that the privileges granted to providers are consistent with the services provided at the Chula Vista CBOC and that privileges are setting specific at Chula Vista and Escondido CBOCs.
Closure Date:
12 We recommended that OPPE data be maintained in all providers¿ profiles at the Escondido CBOC.
Closure Date:
13 We recommended that managers collect and analyze data for hand hygiene at the Carson Valley and Sierra Foothills CBOCs.
Closure Date:
14 We recommended that the VISN and Facility Directors ensure that the deficiencies at the Escondido CBOC are addressed and corrected to ensure compliance with the ADA requirements.
Closure Date:
15 We recommended that the Chula Vista CBOC implement a process to ensure that patient PII is protected and secured.
Closure Date:
16 We recommended that the Network Contracting Office, in conjunction with VISN and Facility Directors, award a competitive long-term contract and to ensure that future acquisitions allow for adequate planning time to avoid the need for ICA.
Closure Date:
17 We recommended that the Service Area Office (SAO) West Director and MSO Directors ensure that the use of ICA complies with VA directives.
Closure Date:
18 We recommended that the SAO West Director and Network Contract Manager ensure appropriate oversight and enforcement of VA directives before an ICA is approved and a contract is signed.
Closure Date:
19 We recommended that the SAO West Director and Network Contract Manager ensure that contracting officers are held accountable for noncompliance with VA directives.
Closure Date:
20 We recommended that the Facility Director and Network Contract Manager confer with Regional Counsel to determine the amount and collectability of all overpayments.
Closure Date:
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| 12-01758-40 | Healthcare Inspection – Alleged Clinical and Administrative Issues, VA Loma Linda Healthcare System, Loma Linda, CA | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that MH patients receive timely care, including initial evaluations within 24 hours and comprehensive evaluations within 14 days.
Closure Date:
2 We recommended that the Facility Director establish a MH Executive Council as required by VHA.
Closure Date:
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| 11-03655-30 | Community Based Outpatient Clinic Reviews Brooklyn (Chapel Street) and Sunnyside (Queens), NY; Franklin (Venango), PA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Chapel Street CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
2 We recommended that the Chapel Street CBOC clinicians document education of foot care to diabetic patients in CPRS.
Closure Date:
3 We recommended that the Queens CBOC clinicians document complete foot screenings for diabetic patients in CPRS.
Closure Date:
4 We recommended that the Queens CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
5 We recommended that the Venango CBOC clinicians document assessment of therapeutic footwear and/or orthotics for diabetic patients with risk assessment Level 2 or 3.
Closure Date:
6 We recommended that the security of PII on laboratory specimens is ensured when they are transported from the Chapel Street CBOC.
Closure Date:
7 We recommended that patient privacy in the examination rooms is ensured at the Queens CBOC.
Closure Date:
8 We recommended that the security of PII on laboratory specimens is ensured when they are transported from the Queens CBOC.
Closure Date:
9 We recommended that Venango CBOC staff secure the view of PII on computer screens.
Closure Date:
10 We recommended that managers develop a local policy for MH and/or medical emergencies that reflects the current practice and capability at the Queens CBOC.
Closure Date:
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| 12-03074-29 | Combined Assessment Program Review of the VA Northern California Health Care System, Sacramento, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the MEC.
Closure Date:
2 We recommended that processes be strengthened to ensure that IC Functional Committee meeting minutes include sufficient data analysis and planning for corrective actions.
Closure Date:
3 We recommended that processes be strengthened to ensure that all food items are labeled with expiration dates, that patient nutritional products are routinely inspected to ensure they are within their expiration dates, and that hand hygiene products are readily available.
Closure Date:
4 We recommended that processes be strengthened to ensure that expired medications are removed and stored separately from medications available for administration.
Closure Date:
5 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Closure Date:
6 We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are developed for all polytrauma outpatients who require them.
Closure Date:
7 We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
Closure Date:
8 We recommended that the facility monitor compliance with its polytrauma training requirements.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology that was approved in September 2012.
Closure Date:
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| 12-02600-28 | Combined Assessment Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 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:
2 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:
3 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
Closure Date:
4 We recommended that processes be strengthened to ensure that test strips are stored and glucometers are maintained in accordance with the manufacturers¿ recommendations.
Closure Date:
5 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
6 We recommended that processes be strengthened to ensure that staff make and document post-discharge telephone calls in accordance with local policy.
Closure Date:
7 We recommended that the locked acute MH unit have camera surveillance monitoring at all required locations.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PR Committee is consistently notified when corrective actions are completed and that this notification is documented in the meeting minutes.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Medical Records Committee provides oversight and coordination of EHR quality reviews and that EHR quality reviews are consistently completed for all services, including Surgical Service.
Closure Date:
10 We recommended that processes be strengthened to ensure that aggregated data from resuscitation episodes is reported to the CPR Subcommittee monthly and documented in the meeting minutes.
Closure Date:
11 We recommended that all required services be available to polytrauma outpatients and that minimum staffing levels be maintained.
Closure Date:
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| 12-01877-25 | Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 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:
2 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:
3 We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that all discharged MH patients receive follow-up within 7 days of discharge and that compliance be monitored.
Closure Date:
6 We recommended that the facility offer MH services at least one evening per week.
Closure Date:
7 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
Closure Date:
9 We recommended that processes be strengthened to ensure that patient care areas and fall mats are clean.
Closure Date:
10 We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
Closure Date:
11 We recommended that processes be strengthened to ensure that sensitive patient information displayed on computer screens is secured.
Closure Date:
12 We recommended that processes be strengthened to ensure that final summary notes for ethics consults pertaining to active clinical cases are documented in the EHRs.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
Closure Date:
14 We recommended that processes be strengthened to ensure that glucometers are cleaned and maintained in accordance with the manufacturer's recommendations.
Closure Date:
15 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Closure Date:
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| 12-02188-15 | Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the holes in the walls be repaired and that processes be strengthened to ensure that patient care areas are clean.
Closure Date:
2 We recommended that the DRRTP have Class K fire extinguishers available in the kitchens used by residents.
Closure Date:
3 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
Closure Date:
4 We recommended that processes be strengthened to ensure that designated employees at the John Cochran dental clinic complete initial laser safety training and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that needle safety devices are available in the Jefferson Barracks dental clinic and that use of the devices be monitored.
Closure Date:
6 We recommended that DRRTP and SA RRTP managers update the policies to safely manage medications and written procedures for contraband detection to include all VHA requirements and that compliance with the updated policies and procedures be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that monthly DRRTP and SA RRTP self-inspections are conducted and that documentation includes all required elements and corrective actions taken when deficiencies are identified.
Closure Date:
8 We recommended that processes be strengthened to ensure that daily SA RRTP resident room inspections are thorough.
Closure Date:
9 We recommended that processes be strengthened to ensure that SA RRTP rooms occupied by female veterans are safe, private, and secure.
Closure Date:
10 We recommended that processes be strengthened to ensure that all non-physician employees complete the facility¿s required training program prior to assisting with or providing moderate sedation.
Closure Date:
11 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that informed consents are completed for all patients undergoing moderate sedation and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
Closure Date:
13 We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
Closure Date:
14 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:
15 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:
16 We recommended that processes be strengthened to ensure that all patients discharged from inpatient MH receive follow-up MH appointments prior to being discharged.
Closure Date:
17 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
Closure Date:
18 We recommended that the annual staffing plan reassessment process ensure that unit 6N's unit-based expert panel includes representatives from all nursing roles.
Closure Date:
19 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:
20 We recommended that unit 6N's nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
21 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results have a comprehensive evaluation within the required timeframe.
Closure Date:
22 We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are provided to polytrauma outpatients and/or the patients' families.
Closure Date:
23 We recommended that processes be strengthened to ensure that staff in all testing areas are aware of the location of the current electronic glucose POCT manual.
Closure Date:
24 We recommended that processes be strengthened to ensure that staff complete the action required in response to critical test results and document in the glucometer or EHR the name of the specific provider notified of the critical test results.
Closure Date:
25 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:
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14917