Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-09017-64 | Review of Staffing and Access Concerns at the Mann-Grandstaff VA Medical Center Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Mann-Grandstaff VA Medical Center Director takes action to ensure that patients have timely access to care.
Closure Date:
2 The Mann-Grandstaff VA Medical Center Director ensures continued implementation of corrective actions in response to deficient areas identified in the National Program Office for Sterile Processing report.
Closure Date:
| ||||
| 19-06871-59 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 4: VA Healthcare, Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The chief medical officer ensures that facilities’ Executive Committees of the Medical Staff document its decision to recommend privileges for licensed independent practitioners based on focused and ongoing professional practice evaluation results and monitors facilities’ committee compliance.
Closure Date:
2 The network director ensures the establishment of a Veterans Integrated Service Network emergency management committee and implementation of all committee requirements.
Closure Date:
| ||||
| 19-00468-67 | Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota | Hotline Healthcare Inspection | ||
1 The Minneapolis VA Health Care System Director ensures that Emergency Department staff notify the facility Suicide Prevention Coordinator when a patient presents with suicidal ideation, as required by the Veterans Health Administration.
Closure Date:
2 The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care, including consults, and considers whether an institutional disclosure is warranted.
Closure Date:
3 The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
Closure Date:
4 The Minneapolis VA Health Care System Director ensures that inpatient consult results are acted upon by the responsible provider or appropriate designee and monitors compliance.
Closure Date:
5 The Minneapolis VA Health Care System Director strengthens processes in root cause analyses consistent with Veterans Health Administration requirements.
Closure Date:
6 The Under Secretary for Health ensures that the Veterans Health Administration establishes written guidance for root cause analysis teams to identify lessons learned and expectations regarding related actions.
Closure Date:
7 The Minneapolis VA Health Care System Director ensures that the Patient Safety Committee and Quality Management Council meeting minutes include deliberations and tracking of actions to resolution, as required by Veterans Health Administration and facility policy.
Closure Date:
| ||||
| 18-04666-55 | Comprehensive Healthcare Inspection of the VA Western New York Healthcare System, Buffalo, New York | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff confirms that all team members responding to resuscitation events have basic or advanced cardiac life support certification and monitors compliance.
Closure Date:
2 The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
Closure Date:
3 The chief of staff ensures that service chiefs include required gastroenterology and pathology specific criteria for those specialties in ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
4 The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
5 The chief of staff ensures that the Executive Committee of the Medical Staff reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director and monitors compliance.
Closure Date:
6 The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
Closure Date:
7 The associate director makes certain mental health seclusion room floors are cushioned.
Closure Date:
8 The associate director ensures the required inventory of assets and resources is created and reviewed annually by the Emergency Management Committee and approved by executive leaders and monitors compliance.
Closure Date:
9 The facility director ensures that staff who conduct monthly review of balance adjustments not be the same staff that perform and document the balance adjustments and monitors compliance.
Closure Date:
10 The facility director makes certain that controlled substances coordinators maintain necessary records and controlled substance inspectors conduct monthly physical inventory of the controlled substances storage area that are completed on the day initiated and monitors controlled substance coordinator’s compliance.
Closure Date:
11 The facility director makes certain that the pharmacy staff complete the pharmacy inventory checks as required and monitors staff compliance.
Closure Date:
12 The chief of staff ensures mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
13 The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
Closure Date:
14 The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
Closure Date:
15 The facility director confirms that the facility has a full-time women veterans program manager and monitors compliance.
Closure Date:
16 The facility director makes certain that the Women Veterans Health Committee meets quarterly, is comprised of required core members, reports to executive quadrad leadership with signed minutes, and monitors the committee’s compliance.
Closure Date:
17 The facility director makes certain that the emergency department has a licensed physician privileged to staff the department during all hours of operation and monitors the department’s compliance.
Closure Date:
18 The facility director makes certain the emergency department has the necessary resources readily available to treat sexual assault patients and monitors compliance.
Closure Date:
| ||||
| 19-00015-47 | Comprehensive Healthcare Inspection of the Louis Stokes Cleveland VA Medical Center, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff confirms that clinical managers consistently implement Peer Review Committee’s recommended improvement actions and monitors managers’ compliance.
Closure Date:
2 The chief of staff verifies that all applicable deaths within 24 hours of admission are peer reviewed and monitors Peer Review Committee’s compliance.
Closure Date:
3 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
4 The chief of staff verifies that clinical staff responding to resuscitation events have the required basic or advanced cardiac life support certification and monitors compliance.
Closure Date:
5 The associate director for Patient Care Services makes certain that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
Closure Date:
6 The associate director directs the chief of Engineering to ensure the flooring in the locked mental health unit seclusion room provides cushioning and monitors the chief’s compliance.
Closure Date:
7 The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
8 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
9 The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
Closure Date:
10 The associate director makes certain that directional signage to the emergency department is placed at facility entrances.
Closure Date:
| ||||
| 19-00052-54 | Comprehensive Healthcare Inspection of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures the patient safety manager incorporates all required elements, including consideration of relevant literature and implementation date for action items, into root cause analyses and submits completed analyses to the National Center for Patient Safety within 45 days and monitors the patient safety manager’s compliance.
Closure Date:
2 The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
3 The chief of staff confirms that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided for newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
4 The chief of staff makes certain that clinicians review and reconcile medications and monitors clinicians’ compliance.
Closure Date:
5 The chief of staff makes certain that ordering providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
| ||||
| 19-00055-38 | Comprehensive Healthcare Inspection of the St. Cloud VA Health Care System, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
2 The chief of staff confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
3 The chief of staff ensures that clinicians provide and document patient/caregiver education and evaluate understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
4 The facility director ensures that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
| ||||
| 19-00051-40 | Comprehensive Healthcare Inspection of the Chalmers P. Wylie Ambulatory Care Center, Columbus, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors managers’ compliance.
Closure Date:
2 The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis to ensure quality and consistency of reviews and monitors the patient safety manager’s compliance.
Closure Date:
3 The facility director ensures that the appropriate committee reviews all resuscitative episodes, to include the required components, and monitors committee’s compliance.
Closure Date:
4 The chief of staff ensures that clinical managers define the focused professional practice evaluation process in advance and monitors clinical managers’ compliance.
Closure Date:
5 The chief of staff confirms that clinical managers ensure ongoing professional practice evaluations include service chief’s determination to continue privileges based on the results of the evaluations within the re-privileging period and monitors clinical managers’ compliance.
Closure Date:
6 The chief of staff makes certain that the facility’s Medical Executive Board considers ongoing professional practice evaluation results in its decision to recommend continuation of provider privileges and monitors compliance.
Closure Date:
7 The facility director makes certain that monthly and quarterly controlled substances inspection reports are reviewed at least on a quarterly basis by the facility committee responsible for quality oversight and that identified corrective actions are followed up until completion and monitors compliance.
Closure Date:
8 The chief of staff ensures that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
9 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
10 The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
Closure Date:
11 The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
12 The chief of staff ensures that ordering providers notify patients of abnormal results within the required time frame and monitors providers’ compliance.
Closure Date:
13 The facility director ensures that the chief of staff makes certain that all anesthesia providers follow required steps to ensure consistent and safe handling, storage, and security of controlled substances and monitors compliance.
Closure Date:
| ||||
| 19-00048-48 | Comprehensive Healthcare Inspection of the Coatesville VA Medical Center, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that all required representatives consistently participate in the interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
2 The facility director ensures that managers consistently implement corrective actions identified in root cause analyses and monitors compliance.
Closure Date:
3 The chief of staff ensures that the Medical Executive Board reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director.
Closure Date:
4 The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
Closure Date:
5 The associate director verifies that the inventory of resources and assets that may be needed during an emergency is documented and reviewed annually and monitors compliance.
Closure Date:
6 The associate director ensures that emergency generators are tested in accordance with required standards and results are documented and monitors compliance.
Closure Date:
7 The facility director makes certain that controlled substances inspectors are appointed in writing and monitors compliance.
Closure Date:
8 The facility director makes certain that the controlled substances coordinators complete annual competency assessment of inspectors and monitors coordinators’ compliance.
Closure Date:
9 The facility director makes certain that the controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities and monitors coordinators’ compliance.
Closure Date:
10 The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
11 The chief of staff makes certain that clinicians document patient and/or caregiver understanding of the education provided about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
Closure Date:
12 The chief of staff makes certain the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
13 The facility director makes certain that if the urgent care center operates 24 hours a day, seven days a week, that the national director of Emergency Medicine has approved a waiver.
Closure Date:
14 The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors the center’s compliance.
Closure Date:
15 The facility director ensures that support services are available to the urgent care center during all hours of operation and monitors compliance.
Closure Date:
16 The facility director makes certain the urgent care center does not receive patients via ambulance and monitors compliance.
Closure Date:
| ||||
| 17-03718-240 | Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Order Fulfillment and Performance Reporting for Eastern Area Medical Centers | Audit | ||
1 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to develop a formal process to validate correct order fulfillment reporting by the prime vendors, ensure the correct algorithms are used, and help prevent missed opportunities to identify and mitigate issues.
2 The executive in charge, office of under secretary for health, requires the Healthcare Commodities Program Office to ensure Medical/Surgical Prime Vendor Next Generation contracting officer’s representatives get timely access to the performance metric reporting, such as reporting on correct order fulfillment.
Closure Date:
3 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor contracting officer’s representatives to ensure performance metric reporting is reviewed for accuracy.
Closure Date:
4 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to strengthen processes and procedures so that staff use the Medical/Surgical Prime Vendor Next Generation formulary to change unit of issuance and product pricing information in the item master files.
Closure Date:
5 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to confirm that prime vendor American Medical Depot uses formulary sources when fulfilling requests for medical or surgical products under the Medical/Surgical Prime Vendor Next Generation.
Closure Date:
6 The executive in charge, office of under secretary for health, requires the director, VHA Procurement and Logistics Office, to see that all those who order supplies under the Medical/Surgical Prime Vendor-Next Generation contract have proper delegated authority.
Closure Date:
7 The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor the Integrated Product Team’s development and implementation of a process to validate performance metric reporting such as on unadjusted fill rates.
8 The executive in charge, office of under secretary for health, requires the Procurement and Logistics Office to strengthen controls, monitor the Healthcare Commodities Program Office monthly, and ensure adherence to the established Medical/Surgical Prime Vendor Next Generation program control plan.
9 The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to identify and resolve discrepancies between unadjusted fill rate reporting methods used by the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers.
Closure Date:
10 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, direct the Healthcare Commodities Program Office and Strategic Acquisition Center to see that all prime vendors use the unadjusted fill rate calculation methodology in accordance with the Medical/Surgical Prime Vendor Next Generation contract.
Closure Date:
11 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, instruct the Healthcare Commodities Program Office and Strategic Acquisition Center to require the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers to provide corrected unadjusted fill rates for the fiscal year 2018 and current reporting periods.
Closure Date:
| ||||
14957