Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00023-29 | Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System, Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 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:
2 The chief of staff confirms that clinical managers ensure that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors managers’ compliance.
Closure Date:
3 The associate director for Patient Care Services ensures staff remove expired medications from service and monitors staff compliance.
Closure Date:
4 The associate director for Patient Care Services makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
Closure Date:
5 The associate director makes certain staff use privacy screens on all computer monitors located in public areas and monitors staff compliance.
Closure Date:
6 The associate director ensures that the Leeward Oahu VA Clinic waiting room carpet is replaced.
Closure Date:
7 The chief of staff ensures that Leeward Oahu VA Clinic staff secure laboratory transport boxes containing personally identifiable information and monitors staff compliance.
Closure Date:
8 The facility director ensures that controlled substances inspectors verify controlledsubstances orders for five random dispensing activities during monthly area inspectionsand monitors inspectors’ compliance.
Closure Date:
9 The chief of staff confirms that mental health and primary care providers completemilitary sexual trauma mandatory training within the required time frame and monitorsproviders’ compliance.
Closure Date:
10 The chief of staff confirms that the Women Veterans Health Committee is comprised of required members and monitors the committee’s compliance.
Closure Date:
11 The chief of staff makes certain that program managers collect and track cervical cancer screening notification, results reporting, and follow-up care data and monitors program managers’ compliance.
Closure Date:
12 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
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| 19-00014-33 | Comprehensive Healthcare Inspection of the Northern Arizona VA Health Care System, Prescott, Arizona | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
2 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
3 The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.
Closure Date:
4 The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.
5 The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.
6 The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
7 The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.
8 The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
9 The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.
Closure Date:
10 The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.
Closure Date:
11 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.
Closure Date:
12 The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
Closure Date:
13 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
14 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:
15 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:
16 The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.
Closure Date:
17 The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.
Closure Date:
18 The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
19 The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
Closure Date:
20 The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.
Closure Date:
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| 19-00019-26 | Comprehensive Healthcare Inspection of the Sioux Falls VA Health Care System, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
2 The chief of staff ensures that the imaging service chief includes the minimum required specialty-specific criteria for focused professional practice evaluations of nuclear medicine practitioners and monitors imaging service chief’s compliance.
Closure Date:
3 The associate director confirms that facility managers replace or remove damaged furnishings and wheelchairs from service and monitors compliance.
Closure Date:
4 The facility director makes certain that the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substance orders and monitors inspectors’ compliance.
Closure Date:
5 The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
6 The chief of staff makes certain that clinicians provide and document patient and/or caregivers education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
7 The facility director ensures the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
8 The facility director makes certain that the emergency department is staffed with a minimum of two registered nurses during all hours of operation and monitors compliance.
Closure Date:
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| 18-00711-211 | Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Boston VA Research Institute | Audit | ||
1 The under secretary for health confer with VA Office of General Counsel and the VA Boston Healthcare System Human Resources Office to determine if administrative actions should be taken concerning VA Boston Healthcare System officials responsible for the $1.6 million in inappropriate payments to the Boston VA Research Institute.
Closure Date:
2 The under secretary for health determine appropriate actions for the inappropriate overpayments, made by VA Boston Healthcare System officials, associated with salaries and fringe benefits for ineligible Boston VA Research Institute administrative staff, as well as duplicate employer retirement contribution payments.
Closure Date:
3 The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Human Resources Office develops procedures to require reviews of VA-affiliated nonprofit corporation Intergovernmental Personnel Act agreements for compliance with VA Handbook 5005, Staffing, prior to approval.
Closure Date:
4 The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Research and Development Budget Office develops procedures for adequate review of VA-affiliated nonprofit corporation invoices to prevent duplicate payments in accordance with VA financial policy prior to approval.
Closure Date:
5 The VA Boston Healthcare System director determine appropriate actions to ensure procedures are developed that require the VA Boston Healthcare System Research and Development Budget Office supervisor to conduct periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
Closure Date:
6 The VA Boston Healthcare System director establish procedures to ensure research and development budget office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with the agreement prior to payment.
Closure Date:
7 The VA Boston Healthcare System director establish procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff to prevent improper payments, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
Closure Date:
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| 18-04671-25 | Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System, California | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that clinicians complete peer reviews for all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
Closure Date:
2 The associate director for Patient Care Services ensures utilization management reviewers complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors reviewers’ compliance.
Closure Date:
3 The associate director for Patient Care Services ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
Closure Date:
4 The associate director for Patient Care Services makes certain that staff label multidose medication vials with an expiration date upon opening and monitors staff compliance.
Closure Date:
5 The associate director for Operations ensures that managers maintain a safe environment in patient care areas and monitors managers’ compliance.
Closure Date:
6 The associate director for Operations ensures that San Luis Obispo VA Clinic staff secure laboratory transport bags containing personally identifiable information and monitors staff compliance.
Closure Date:
7 The associate director for Operations ensures the VA police document response times for panic alarm testing at the locked inpatient mental health unit and monitors compliance.
Closure Date:
8 The associate director for Operations makes certain that bathroom faucets in the inpatient mental health unit are in compliance with the Mental Health Environment of Care Checklist and monitors compliance.
Closure Date:
9 The facility director ensures that the controlled substances coordinator’s monthly summary report includes all discrepancies and findings identified during inspections and monitors coordinator’s compliance.
Closure Date:
10 The facility director makes certain that a quality management committee consistently reviews monthly and quarterly controlled substances program trend reports, including discrepancies identified during inspections, and monitors committee’s compliance.
Closure Date:
11 The facility director makes certain that controlled substances inspectors are appointed in writing to a term not to exceed three years and monitors compliance.
Closure Date:
12 The facility director ensures that the controlled substances coordinator performs and documents competency assessments of the controlled substances inspectors annually and monitors controlled substances coordinator’s compliance.
Closure Date:
13 The facility director confirms that controlled substances inspectors complete monthly inspections and physical inventory counts and monitors inspectors’ compliance.
Closure Date:
14 The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors program staff’s compliance.
Closure Date:
15 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:
16 The facility director makes certain that the controlled substances coordinator refrains from conducting routine inspections and monitors coordinator’s compliance.
Closure Date:
17 The facility director confirms that controlled substances inspectors complete monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
18 The facility director ensures that controlled substances inspectors verify that drugs held for destruction are secured and documented during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
19 The facility director makes certain that controlled substances inspectors verify the inventory count of prescription pads the day of the pharmacy inspection and monitors inspectors’ compliance.
Closure Date:
20 The facility director ensures that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
21 The facility director guarantees that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
Closure Date:
22 The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
Closure Date:
23 The chief of staff certifies that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
24 The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
Closure Date:
25 The chief of staff ensures that the Women Veterans Health Committee includes required core members, meets at least quarterly, and reports to facility leaders and monitors committee’s compliance.
Closure Date:
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| 19-05916-24 | Alleged Wrongful Death and Deficiencies in Documentation of a Patient’s DNAR Status at the Baltimore VA Medical Center, Maryland | Hotline Healthcare Inspection | ||
1 The VA Maryland Health Care System Director reviews the subject patient’s final episode of care and treatment course and determines if administrative actions are appropriate.
Closure Date:
2 The VA Maryland Health Care System Director establishes a process to monitor the identification, documentation, and communication of patients’ Do Not Attempt Resuscitation status.
Closure Date:
3 The VA Maryland Health Care System Director reviews the process for tracking, documenting, and completing action items in the Executive Committee of the Medical Staff.
Closure Date:
4 The VA Maryland Health Care System Director strengthens the process for tracking code blue/rapid response events to include timely completion of the required documentation and accountability for delinquent documentation.
Closure Date:
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| 19-00033-11 | Comprehensive Healthcare Inspection of the El Paso VA Health Care System, Texas | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that mental health service chiefs clearly define and communicate expectations for focused professional practice evaluations in advance with providers and monitors service chiefs’ compliance.
Closure Date:
2 The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
3 The facility director ensures the emergency management coordinator conducts an annual inventory of resources and assets and monitors coordinator’s compliance.
Closure Date:
4 The facility director ensures that an emergency operations plan that describes the response procedures to follow when emergencies occur is developed and maintained as required.
Closure Date:
5 The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
6 The chief of staff ensures that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
7 The chief of staff makes certain that the Women Veterans Health Committee reports to leaders with signed minutes and monitors committee’s compliance.
Closure Date:
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| 18-04667-13 | Comprehensive Healthcare Inspection of the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures clinical managers initiate focused professional practice evaluations that clearly define criteria and communicate time frames in advance and monitors clinical managers’ compliance.
Closure Date:
2 The facility director ensures that pharmacy staff who review monthly balance adjustments do not have electronic access to perform controlled substances balance adjustments and monitors staff compliance.
Closure Date:
3 The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
4 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 evaluate understanding when education is provided and monitors clinicians’ compliance.
Closure Date:
5 The facility director confirms that the Women Veterans Health Committee maintains an active charter, meets quarterly at a minimum, and reports to leadership with signed minutes and monitors committee’s compliance.
Closure Date:
6 The chief of staff ensures providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.
Closure Date:
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| 19-00040-10 | Comprehensive Healthcare Inspection of the Manchester VA Medical Center, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 The facility director confirms that the patient safety manager includes consideration of relevant literature in root cause analyses and monitors patient safety manager’s compliance.
Closure Date:
2 The chief of staff ensures that clinical managers document in practitioners’ profiles the focused professional practice evaluation criteria defined in advance and monitors clinical managers’ compliance.
Closure Date:
3 The chief of staff ensures that professional practice evaluations include service-specific criteria and monitors compliance.
Closure Date:
4 The chief of staff confirms that specialty providers’ ongoing professional practice evaluations include the minimum required specialty criteria and monitors compliance.
Closure Date:
5 The chief of staff makes certain that the facility’s Medical Executive Council reviews the professional practice data in the consideration to continue provider privileges and monitors compliance.
Closure Date:
6 The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
Closure Date:
7 The associate director ensures that a clean and safe environment is maintained throughout the facility and monitors compliance.
Closure Date:
8 The facility director ensures that military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
Closure Date:
9 The chief of staff ensures providers offer referrals for military sexual trauma-related services for patients with a positive screen and monitors providers’ compliance.
Closure Date:
10 The facility director confirms 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 ensures providers document indication for use for newly prescribed medications in patients’ electronic health records and monitors providers’ compliance.
Closure Date:
12 The chief of staff ensures that clinicians provide and document patient/caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
13 The chief of staff ensures providers reconcile medication information and resolve discrepancies and monitors the providers’ compliance.
Closure Date:
14 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
15 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 compliance.
Closure Date:
16 The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
Closure Date:
17 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.
Closure Date:
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| 19-00013-15 | Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center, Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors manager compliance.
Closure Date:
2 The chief of staff ensures that final peer reviews are completed within 120 calendar days from the determination of the need for the review, or there is an extension approved in writing by the director, and monitors compliance.
Closure Date:
3 The facility director makes certain that a summary of the Peer Review Committee’s work is reviewed quarterly by the executive level medical committee and monitors compliance.
Closure Date:
4 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
5 The chief of staff makes certain that service chiefs define and communicate expectations for focused professional practice evaluation criteria in advance and maintain appropriate documentation of the processes and monitors service chiefs’ compliance.
Closure Date:
6 The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
Closure Date:
7 The associate director ensures a clean and safe environment is maintained throughout the facility and monitors team’s compliance.
Closure Date:
8 The associate director ensures the facility maintains an inventory of assets and resources available in the event of a disaster and that it is reviewed annually and monitors compliance.
Closure Date:
9 The associate director validates that the facility’s emergency operations plan includes all required elements and is reviewed annually and monitors compliance.
Closure Date:
10 The facility director makes certain that the controlled substances coordinator submits monthly summary of findings and quarterly trends, that include discrepancies and vulnerabilities, to the director and monitors controlled substances coordinator’s compliance.
Closure Date:
11 The facility director makes certain that the appropriate quality management committee reviews the controlled substances monthly and quarterly reports at least on a quarterly basis and monitors compliance.
Closure Date:
12 The facility director makes certain the controlled substances coordinator conducts required annual competency assessments of the controlled substances inspectors and monitors the coordinator’s compliance.
Closure Date:
13 The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substances in storage areas on the day initiated and monitors inspectors’ compliance.
Closure Date:
14 The facility director makes certain that 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 monthly controlled substances area inspections and monitors compliance.
Closure Date:
15 The facility director makes certain the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substances orders during monthly area inspections and monitors compliance.
Closure Date:
16 The facility director makes certain that controlled substances inspectors verify, during monthly inspections, there is a corresponding sealed evidence bag containing drug(s) for each destruction holding number listed on the “Destructions File Holding Report” and monitors inspector’s compliance.
Closure Date:
17 The facility director ensures that controlled substances inspectors complete verification of prescription pad inventories count during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
18 The facility director ensures that the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances prescriptions during monthly area inspections and monitors inspectors’ compliance.
Closure Date:
19 The facility director makes certain that controlled substances inspectors complete the verification of the 72-hour inventory and monitors inspectors’ compliance.
Closure Date:
20 The chief of staff ensures providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
Closure Date:
21 The facility director confirms that the committee responsible for Women Veterans Subcommittee meets quarterly and includes required core members and monitors committee’s compliance.
Closure Date:
22 The facility director ensures that assigned staff implement a process to track and follow-up on findings from cervical cancer screenings and monitors staff’s compliance.
Closure Date:
23 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
24 The chief of staff ensures that a backup call schedule is maintained for emergency department providers and monitors the department’s compliance.
Closure Date:
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15039