Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00038-63 | Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that peer reviewers consistently use at least one of the aspects of care when conducting peer reviews and monitors reviewers’ compliance.
Closure Date:
2 The chief of staff ensures that managers consistently implement, and document completion of improvement actions recommended by the Peer Review Committee and monitors the managers’ compliance.
Closure Date:
3 The chief of staff ensures that peer review data is reported quarterly to the Executive Committee of the Medical Staff and monitors compliance.
Closure Date:
4 The facility director ensures utilization management staff complete and document acute inpatient and observations stay reviews as required and monitors staff compliance.
Closure Date:
5 The facility director ensures that Physician Utilization Management Advisor(s) consistently complete reviews and document their decisions in the National Utilization Management Integration database and monitors compliance.
Closure Date:
6 The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
Closure Date:
7 The facility director ensures that the patient safety manager or designee completes the required number of root cause analyses that include the required content annually and monitors the patient safety manager’s compliance.
Closure Date:
8 The facility director ensures that the patient safety manager or designee provides an annual patient safety report to facility leaders and monitors the patient safety manager’s compliance.
Closure Date:
9 The chief of staff ensures that clinical managers clearly define the criteria, time frames, and expectations with providers in advance for focused professional practice evaluations and monitors the clinical managers’ compliance.
Closure Date:
10 The chief of staff makes certain that the Executive Committee of the Medical Staff reviews and evaluates the focused and ongoing professional practice evaluation results and monitors compliance.
Closure Date:
11 The associate director ensures that patients areas are clean and that action is taken to minimize or eliminate identified safety risks in the environment and monitors compliance.
Closure Date:
12 The facility director ensures that controlled substances inspectors are appointed in writing with a term not to exceed three years and monitors compliance.
Closure Date:
13 The facility director ensures that monthly reconciliation of one day’s dispensing from pharmacy to every automated dispensing cabinet and one day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
Closure Date:
14 The facility director ensures that controlled substances inspectors verify there is evidence of a written or electronic controlled substances order for five randomly selected dispensing activities during monthly inspections and monitors compliance.
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15 The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
Closure Date:
16 The chief of staff confirms that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
Closure Date:
17 The chief of staff certifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided, and monitors clinicians’ compliance.
Closure Date:
18 The chief of staff ensures clinicians complete and document medication reconciliation as required and monitors the clinicians’ compliance.
Closure Date:
19 The facility director confirms that the Women Veterans Health Committee meets at least quarterly, includes required core members, and reports to the appropriate executive committee and monitors the committee’s compliance.
Closure Date:
20 The chief of staff ensures tracking and monitoring of cervical cancer data and monitors compliance.
Closure Date:
21 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
22 The facility director makes certain that the facility has an approved waiver from the national director of Emergency Medicine if the urgent care center continues to operate 24 hours a day, seven days a week.
Closure Date:
23 The facility director ensures that the urgent care center is staffed with at least two registered nurses physically present during all hours of operation and monitors compliance.
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24 The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
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25 The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
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26 The facility director makes certain that social work services are available to the urgent care center during all hours of operation, and monitors compliance.
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27 The facility director ensures that action plans are developed and implemented for underperforming patient flow metrics in the urgent care center and monitors compliance.
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28 The facility director makes certain that appropriate signage is in place to direct patients to the urgent care center and monitors compliance.
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29 The facility director ensures that at least one room is identified as the psychiatric intervention room in the urgent care center and monitors compliance.
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30 The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.
Closure Date:
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| 19-00037-58 | Comprehensive Healthcare Inspection of the Canandaigua VA Medical Center, New York | Comprehensive Healthcare Inspection Program | ||
1 The associate director makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
Closure Date:
2 The associate director makes certain that VA police conduct and document monthly panic alarm testing at the Rochester VA clinic and monitors VA police compliance.
Closure Date:
3 The associate director makes certain that managers maintain a safe environment and ensure furnishings are in good repair at the Rochester VA clinic and monitors managers’ compliance.
Closure Date:
4 The associate director ensures that Rochester VA clinic staff secure laboratory transport boxes containing personally identifiable information and monitors clinic staff compliance.
Closure Date:
5 The facility director ensures that controlled substances program staff consistently reconcile one day’s dispensing from the pharmacy to each automated dispensing unit and monitors controlled substance inspectors’ compliance.
Closure Date:
6 The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
Closure Date:
7 The facility director makes certain that controlled substances coordinators refrain from conducting routine inspections and monitors coordinators’ compliance.
Closure Date:
8 The facility director certifies that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
9 The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
Closure Date:
10 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
Closure Date:
11 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
12 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
13 The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
14 The facility director makes certain that the Women Veterans Health Committee includes required core members and that members consistently attend meetings and monitors the committee’s compliance.
Closure Date:
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| 19-00016-61 | Comprehensive Healthcare Inspection of the VA Maryland Health Care System, Baltimore, Maryland | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures that peer reviews are completed within 120 calendar days or that a written extension is requested and approved by the facility director and monitors peer review coordinator’s compliance.
Closure Date:
2 The chief of staff ensures reporting of peer review data to the Executive Council of the Medical Staff at least quarterly and monitors compliance.
Closure Date:
3 The chief of staff ensures that all applicable deaths occurring within 24 hours of admission undergo a peer review and monitors compliance.
Closure Date:
4 The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
Closure Date:
5 The facility director ensures 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:
6 The facility director ensures the patient safety manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors patient safety manager’s compliance.
Closure Date:
7 The chief of staff ensures that resuscitative actions performed by staff are in accordance with life-sustaining treatment orders and monitors compliance.
Closure Date:
8 The facility director ensures that the Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
Closure Date:
9 The chief of staff ensures the service chiefs document the focused professional practice evaluation results in the provider’s profile and monitors compliance.
Closure Date:
10 The chief of staff makes certain that the facility’s Executive Committee of the Medical Staff Professional Standards Board reviews all data when recommending continuation of provider privileges and monitors the Committee’s compliance.
Closure Date:
11 The chief of staff ensures that service chiefs include reviews of relevant data in professional practice evaluations when determining continuation of provider’s privileges and monitors service chiefs’ compliance.
Closure Date:
12 The chief of staff ensures the service chiefs include service-specific criteria in professional practice evaluations and monitors compliance.
Closure Date:
13 The associate director ensures that areas used by patients are clean and safe and monitors compliance.
Closure Date:
14 The associate director confirms that damaged furniture and wheelchairs are repaired or removed from service and monitors compliance.
Closure Date:
15 The facility director makes certain that the basement tunnel at Perry Point VA is free from water hazards and monitors compliance.
Closure Date:
16 The associate director certifies that panic alarms are installed and tested as required and monitors compliance.
Closure Date:
17 The associate director ensures that panic alarms on the locked mental health unit are tested to include VA police response time and monitors compliance.
Closure Date:
18 The facility director makes certain that controlled substances inspectors verify controlled substances orders monthly for each medication dispensing cabinet and monitors inspectors’ compliance.
Closure Date:
19 The facility director makes certain that monthly reconciliation of one-day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
Closure Date:
20 The facility director confirms that controlled substances inspectors complete emergency drug cache inspections, including verification of lock numbers, and monitors inspectors’ compliance.
Closure Date:
21 The Facility director makes certain that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
Closure Date:
22 The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors committee’s compliance.
Closure Date:
23 The facility director ensures that there is a defined process in place and designated staff responsible for tracking and monitoring of cervical cancer screenings as required and monitors compliance.
Closure Date:
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| 19-00053-57 | Comprehensive Healthcare Inspection of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that service chiefs initiate and complete focused professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
2 The chief of staff makes certain that service chiefs’ determination to recommend continuation of privileges be based in part on results of ongoing professional practice activities and monitors service chiefs’ compliance.
Closure Date:
3 The chief of staff ensures that the Clinical Executive Board document its decision to recommend privileges based on focused and ongoing professional practice evaluation results and monitors the board’s compliance.
Closure Date:
4 The associate director makes certain staff protect patient identification and health information on all computer monitors and monitors staff compliance.
Closure Date:
5 The facility director makes certain monthly panic alarm testing is performed and evidence is maintained at the Lewiston VA Clinic and monitors compliance.
Closure Date:
6 The associate director makes certain that the floors and walls are safe and in good condition at the Lewiston VA Clinic and monitors compliance.
Closure Date:
7 The associate director ensures that the chief of Facilities Management Service completes and documents weekly emergency generator inspections and monitors compliance.
Closure Date:
8 The associate director ensures that the Facilities Management Service chief annually tests all generators requiring an annual supplemental load and monitors compliance.
Closure Date:
9 The associate director ensures that the Facilities Management Service chief tests the emergency generators at least once every 36 months for a minimum of continuous four hours and monitors compliance.
Closure Date:
10 The facility director ensures that controlled substances inspection staff reconcile one day’s dispensing from the pharmacy to the automated dispensing unit and monitors coordinator’s compliance.
Closure Date:
11 The facility director makes certain that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
12 The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors coordinator’s compliance.
Closure Date:
13 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leaders and monitors coordinator’s compliance.
Closure Date:
14 The chief of staff ensures providers complete initial evaluations within the required time frame for all new patients referred for mental health services for military sexual trauma and monitors providers’ compliance.
Closure Date:
15 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
16 The facility director confirms that the Women Veterans Health Committee members attend meetings consistently and monitors the committee’s compliance.
Closure Date:
17 The chief of staff ensures that ordering providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
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| 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:
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| 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:
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| 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:
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| 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:
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| 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:
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| 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:
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15039