Recommendations
2080
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00265-231 | Comprehensive Healthcare Inspection of the Providence VA Medical Center in Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
Closure Date:
3 The Associate Director for Patient Care evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
| ||||
| 21-00254-213 | Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide prevention safety plans.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that inter-facility transfers are monitored and evaluated.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and ensures that appropriately-privileged providers complete or cosign the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to inter-facility patient transfers.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that transferring physicians send active medication lists to receiving facilities during inter-facility transfers.
Closure Date:
5 The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Closure Date:
| ||||
| 20-01917-242 | Mismanagement of a Patient at the Tomah VA Medical Center in Wisconsin | Hotline Healthcare Inspection | ||
1 The Tomah VA Medical Center Director ensures that providers receive education regarding the management of alcohol withdrawal and delirium tremens, and monitors compliance.
Closure Date:
2 The Tomah VA Medical Center Director makes certain providers consider patients’ underlying cardiac risk prior to the order of haloperidol.
Closure Date:
3 The Tomah VA Medical Center Director conducts a comprehensive review of the patient’s cardiopulmonary resuscitation event to determine potential causes of failed oxygen delivery including systemic root causes and performance deficiencies, and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted and takes action.
Closure Date:
4 The Tomah VA Medical Center Director implements actions recommended by the Out of Operating Room Airway Management workgroup, and monitors compliance.
Closure Date:
5 The Tomah VA Medical Center Director evaluates staff adherence to the Tomah VA Medical Center Policy MS-25, Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Protocol and the Standard Operating Procedure for Nursing Procedure, Symptom Triggered CIWA-Ar Protocol, and takes action to ensure compliance.
Closure Date:
6 The Tomah VA Medical Center Director ensures inpatient medical unit providers and nursing staff compliance with patient restraint management, as required by to the Tomah VA Medical Center Policy, PCS-03, Restraint and Seclusion Use.
Closure Date:
7 The Tomah VA Medical Center Director monitors provider compliance with Tomah VA Medical Center Policy MS-06, Admission Criteria for Acute Medicine Unit.
Closure Date:
8 The Tomah VA Medical Center Director consults with the Office of General Counsel to ensure the Tomah VA Medical Center Policy PCS-SW-17 Emergency Detention is consistent with Wisconsin law.
Closure Date:
9 The Tomah VA Medical Center Director strengthens processes for staff to consider next of kin or family notification in the emergency detention of patients who may not comprehend their legal rights.
Closure Date:
10 The Tomah VA Medical Center Director ensures compliance with institutional disclosure procedures, as required by the Veterans Health Administration.
Closure Date:
| ||||
| 21-01502-240 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2020 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement action items recommended by the committees responsible for quality, safety, and value oversight functions.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facilities peer review all applicable suicides.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that root cause analyses include a review of the underlying systems to determine where system redesigns might reduce risk.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement approved root cause analysis action items and outcome measures show sustained improvement.
Closure Date:
| ||||
| 21-00246-228 | Comprehensive Healthcare Inspection of the VA Eastern Colorado Health Care System in Aurora | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator participates on the Quality Safety Values Executive Council.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Staff regularly attends Surgical Work Group meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff complete suicide safety plan training prior to developing suicide safety plans.
Closure Date:
4 The System Director evaluates and determines reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
5 The System Director evaluates and determines additional reasons for noncompliance and ensures that all patient transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
7 The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
| ||||
| 21-00371-222 | Deficiencies in the Assessment and Care of a Patient Seeking Geriatric Services at the Fayetteville VA Medical Center in North Carolina | Hotline Healthcare Inspection | ||
1 The Fayetteville VA Medical Center Director ensures that community health nurses evaluate patients referred for homemaker and/or home health aide services in accordance with Veterans Health Administration policy when determining patient eligibility.
Closure Date:
2 The Fayetteville VA Medical Center Director verifies that interdisciplinary assessments of homemaker and/or home health aide referrals are completed to determine patient eligibility for services.
Closure Date:
3 The Fayetteville VA Medical Center Director ensures that community health staff are trained on the eligibility criteria for homemaker and/or home health aide services.
Closure Date:
4 The Fayetteville VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of North Carolina commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
Closure Date:
5 The Fayetteville VA Medical Center Director ensures that providers consistently assess and document when patients lack decision-making capacity.
Closure Date:
6 The Fayetteville VA Medical Center Director ensures thatproviders consistently determine whether a patient has an identified healthcare agent when patients lack decision-making capacity.
Closure Date:
7 The Fayetteville VA Medical Center Director makes certain that patient aligned care team providers and outpatient psychiatrists are educated about initiating specialty care consults for patients.
Closure Date:
| ||||
| 20-03359-220 | Deficiencies in Coordination of Care for Patients with Treatment-Resistant Depression at the VA San Diego Healthcare System in California | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health requires that all community care providers authorized to provide ketamine or esketamine for treatment-resistant depression receive and review VA’s National Protocol Guidance on ketamine infusion and intranasal esketamine.
Closure Date:
2 The Under Secretary for Health evaluates the need for conducting research on the use of ketamine and esketamine for treatment-resistant depression including the comparative efficacy of ketamine and esketamine, the effect of route of administration, therapeutic dose range, mechanism of action, and efficacy and safety of long-term treatment, and initiates research efforts as indicated.
Closure Date:
3 The VA San Diego Healthcare System Director confirms that the facility’s Community Care Service takes timely actions to ensure that administrative processes for care authorization do not disrupt continuity of clinical care.
Closure Date:
4 The VA San Diego Healthcare System Director makes certain that the facility’s Community Care Service processes incorporate relevant clinical service input in decisions regarding authorization, denial, or discontinuation of care.
Closure Date:
5 The VA San Diego Healthcare System Director ensures that the facility’s Community Care Service processes incorporate a consistent mechanism for communication with Veterans Health Administration and community clinical providers and patients to facilitate well-timed coordination of care.
Closure Date:
6 The VA San Diego Healthcare System Director monitors implementation of the coordinated, clinically informed plans for continuing care when transitioning the remaining patients from ketamine treatment in the community to care at the facility.
Closure Date:
| ||||
| 21-00232-205 | Comprehensive Healthcare Inspection of the Montana VA Health Care System in Fort Harrison | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator reports directly to the Director or one supervisory level below the Director.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and core members consistently attend meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group reviews surgical deaths and National Surgery Office surgical quality reports, analyzes efficiency and utilization metrics, and recommends appropriate actions to the System Director.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures that specific action items are implemented and monitored when problems or opportunities for improvement are identified.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory training prior to developing suicide safety plans.
Closure Date:
7 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
8 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
| ||||
| 20-01508-214 | Review of Veterans Health Administration Staffing Models | National Healthcare Review | ||
1 The Under Secretary for Health coordinates with VA to review the roles, responsibilities, and number of staff required for the VA and Veterans Health Administration offices involved in the development, validation, and implementation of staffing models, and ensure that staffing model-related efforts are prioritized and supported.
2 The Under Secretary for Health coordinates with VA to evaluate the status of, and provide a timeline for, the development, validation, and implementation of Veterans Health Administration staffing models for all occupations.
Closure Date:
3 The Under Secretary for Health coordinates with VA to evaluate the status of, and provide a timeline for, the implementation of HR Smart-related requirements referenced in VA and Veterans Health Administration policy, with a specific focus on the authorizations, vacancies, budgeted positions, and unbudgeted requirements at the facility, Veterans Integrated Service Network, and national levels.
| ||||
| 20-03635-217 | Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
Closure Date:
2 The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
Closure Date:
3 The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
Closure Date:
4 The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
Closure Date:
5 The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
Closure Date:
6 The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
Closure Date:
7 The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
Closure Date:
8 The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
Closure Date:
9 The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Closure Date:
| ||||
15042