All Reports

Community Based Outpatient Clinic and Primary Care Clinic Reviews at Central Alabama Veterans Health Care System, Montgomery, Alabama
|
14-00930-14

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Dothan and Wiregrass CBOCs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that managers ensure that material safety data sheets are readily available to staff at the Wiregrass CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Dothan CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that processes are improved to ensure the tracking of chemical inventories at the Dothan CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that the effectiveness of the panic alarm system is evaluated at the Wiregrass CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that panic alarms are tested and testing is documented at the Dothan and Wiregrass CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that no clean items are stored in the medical (infectious) waste storage room at the Wiregrass CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that signage is installed to identify the medical (infectious) waste storage room at the Wiregrass CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2015
We recommended that computer screens are secured to eliminate viewing of personally identifiable information by unauthorized individuals at the Wiregrass CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that processes are improved to ensure the use of privacy screens on computers in high-traffic areas at the Wiregrass CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that the parent facility maintain evidence of the contractor’s compliance with facility required education, training, planning, and participation in annual disaster exercises for the Dothan and Wiregrass CBOCs.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that the parent facility’s Emergency Management Committee evaluate the Dothan and Wiregrass CBOCs’ emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2017
We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2015
We recommended that staff provide medication counseling/education as required.
Combined Assessment Program Review of the VA Northern California Health Care System, Mather, California
|
14-02081-41

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that the Surgical Work Group meet monthly, include the Chief of Staff as a standing member, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed at least quarterly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that the Medical Records Committee meet quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Function Team meeting minutes document those actions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that processes be strengthened to ensure that rolling equipment and patient weight scales are cleaned on a routine basis and that damaged furniture in patient care areas is repaired or removed from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the eye clinic waiting room carpet be replaced to avoid tripping hazards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the facility's stroke policy be revised to address screening patients for difficulty swallowing and the difference in approach to patients presenting within and after 2 hours of onset of symptoms, that the policy be fully implemented, and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the facility collect and report to the Provision of Care Committee the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that processes be strengthened to ensure that clinicians obtain a partial thromboplastin time test while assessing patients presenting with stroke symptoms and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommend that that processes be strengthened to ensure that initial patient safety screenings are conducted and documented in the electronic health records and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommend that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that facility policy be revised to fully meet VHA requirements and that processes be strengthened to ensure that quarterly Magnetic Resonance Imaging Safety Committee meetings are held and biannual magnetic resonance imaging safety inspections are conducted and that compliance be monitored.
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas
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14-02080-29

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff document monthly restorative nursing services progress notes in residents’ electronic health records and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that residents are offered transfer from their wheelchairs to regular dining chairs during meal periods.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health record.
Combined Assessment Program Review of the Central Alabama Veterans Health Care System, Montgomery, Alabama
|
14-02079-10

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that code data is collected.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2014
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee representatives from Surgery and Anesthesia Services consistently attend meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Prevention Committee minutes document those actions, reflect follow-up on actions implemented to address identified problems, and consistently reflect analysis of surveillance activities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that processes be strengthened to ensure that fluoroquinolone dosages and/or medications ordered at discharge are consistent with the discharge instructions and the pharmacy updates provided to the patient/caregiver and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the electronic health records and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2016
We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2016
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that stroke guidelines be posted on the intensive care unit and the acute medical/surgical unit and that the facility provide a stroke educational program for employees.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2016
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that care plans are updated when community living center residents’ restorative care needs change and that all residents are reassessed for restorative nursing needs at the intervals required by local policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify restorative nursing interventions as needed, and document those modifications and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Minimum Data Set Coordinator collaborate with the Restorative Nurse to communicate pertinent minimum data set and quality indicator data to restorative nursing program staff.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility establish written procedures for handling emergencies in magnetic resonance imaging and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that processes be strengthened to ensure that contrast reaction drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that secondary patient safety screening forms are scanned into the patients’ electronic health records and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that patients with positive colorectal cancer screening test results receive diagnostic testing within the required timeframe and that compliance be monitored.
Combined Assessment Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
|
14-02078-38

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that the Quality Management Board meet at least quarterly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Executive Committee of the Medical Staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are initiated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that the Executive Committee of the Medical Staff discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that processes be strengthened to ensure that all specialty clinic employees receive annual bloodborne pathogens training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that eye clinic exam/procedure room sinks have foot controls, long-blade handles, or automatic no touch sensors.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2015
We recommended that processes be strengthened to ensure that the medical information from non-VA hospitalizations is consistently scanned into the electronic health record and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that processes be strengthened to ensure that clinicians document acknowledgement of their patients¿ recent non-VA hospitalizations.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that processes be strengthened to ensure that all patients are notified of abnormal Pap smear results/values within the expected timeframe and that notification is documented in the electronic health record and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that processes be strengthened to ensure that all patients are notified of normal lab results/values and radiology results within the expected timeframe and that notification is documented in the electronic health record.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that processes be strengthened to ensure that patients and/or their families receive a copy of the safety plan and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that processes be strengthened to ensure that all employees receive Level 1 training and that the training be documented in employee training records.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that processes be strengthened to ensure that residential rehabilitation unit employees perform and document daily inspections for unsecured medications and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that a process be in place to alert residential rehabilitation unit employees when alarmed doors that are not considered main points of entry are opened from the inside and that the process be tested regularly.
Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota
|
14-02083-24

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that processes be strengthened to ensure that providers complete and document patient discharge progress notes or discharge instructions and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida
|
14-02084-16

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that completed actions from peer reviews are consistently documented in Peer Review Committee meeting minutes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that the Surgical Work Group meet monthly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2015
We recommended that processes be strengthened to ensure that the Blood Utilization Committee representative from Anesthesia Service consistently attends meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2015
We recommended that processes be strengthened to ensure that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2015
We recommended that processes be strengthened to ensure that the negative pressure control systems in the dialysis isolation rooms are functional and that the dialysis unit water treatment, sterile supply, clean utility, and soiled utility room doors are secured at all times and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that equipment is not stored in the restraint room on the locked mental health unit and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that documentation of pachymetry probe reprocessing in the eye clinic is in accordance with the manufacturer’s instructions and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans, document resident progress towards restorative nursing goals, and document reasons why care planned restorative nursing services were not provided or were discontinued and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all potential contraindications prior to the scan and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern California Health Care System, Mather, California
|
14-00937-31

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that processes are improved to ensure compliance with requirements for hazardous materials, including tracking of hazardous materials inventories at the Martinez CBOC, reviewing these inventories twice within a 12-month period at the Martinez and Redding CBOCs, and training Martinez CBOC staff to ensure access to the electronic version of the material safety data sheets.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Fairfield and Martinez CBOCs to the parent facility or contracted processing facility, by securing patient data in the Health Education Room, and through the use of privacy screens on computer monitors at the Martinez Primary Care check-in desk.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that the parent facility’s Emergency Management Committee includes the CBOC in required education, training, planning, and participation leading up to the annual disaster exercise and evaluates the Fairfield, Martinez, and Redding CBOCs’ emergency preparedness activities and participation in annual disaster exercises.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that staff provide and document medication counseling/education as required.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Miami VA Healthcare System, Miami, Florida
|
14-00939-27

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended that the Pembroke Pines CBOC location is clearly identified from the street as a VHA CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that the main entrance and restroom doors at the Key Largo CBOC are accessible per Americans with Disabilities Act guidelines.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2014
We recommended that signage is installed at the Pembroke Pines CBOC to clearly identify the location of fire extinguishers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that exit signs are visible from all directions at the Key Largo CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that personally identifiable information is protected by securing laboratory specimens during transport from the Key Largo and Pembroke Pines CBOCs to the parent facility.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that clinic staff provide adequate privacy for women veterans at the Key Largo and Pembroke Pines CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that access to the information technology server closet at the Key Largo CBOC is documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that staff consistently document and provide written medication information that includes the fluoroquinolones.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that staff consistently document and provide medication counseling/education as required.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that staff consistently document the evaluation of patient's level of understanding for the medication education.
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas
|
14-02076-13

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2014
We recommended that the local observation bed policy be revised to include how the responsible provider is determined and that each observation patient must have a focused goal for the period of observation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that the Surgical Work Group meet monthly, consistently include the Chief of Staff and operating room manager as members, and document its review of National Surgical Office reports.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed at least quarterly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that the quality control policy for scanning include the handling of external source documents.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that processes be strengthened to ensure that the Transfusion Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings and that the blood/transfusions usage review process consistently includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that post-anesthesia care unit employees do not consume beverages in treatment areas and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that the facility's stroke policy be revised to address data gathering for analysis and improvement, that the policy be fully implemented, and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2014
We recommended that stroke guidelines be posted on the intensive care unit, on the medical/surgical unit, and in the community living center.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents' care plans and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2015
We recommended that processes be strengthened to ensure that staff document the reasons for discontinuing or not providing restorative nursing services when those services are care planned and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2015
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that secondary patient safety screening forms are signed by the patient, family member, or caregiver and that compliance be monitored.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that processes be strengthened to ensure that all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Combined Assessment Program Review of the Huntington VA Medical Center, Huntington, West Virginia
|
14-02074-06

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Quality, Safety, and Value Council meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that results of Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently reported to the Medical Staff Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Medical Staff Council discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee collects code data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that processes be strengthened to ensure that the Transfusion Review Committee members from Medicine and Anesthesia Services consistently attend meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that all food service employees use hairnets and gloves when serving food.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that all privacy curtains in same day surgery and on the post-anesthesia care unit have open mesh tops that extend 18 inches for sprinkler coverage.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that same day surgery have designated rooms for the storage of dirty instruments, equipment, and housekeeping supplies and that these rooms and the soiled utility room on the post-anesthesia care unit be secured.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2015
We recommended that processes be strengthened to ensure that designated eye clinic employees receive eye laser safety training annually and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance is monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that stroke guidelines be posted in the emergency department, on the intensive care unit, and on the acute inpatient units.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processed be strengthened to ensure that all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee
|
14-02077-01

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that results of Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently reported to the Medical Executive Board.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Cardiopulmonary Resuscitation Review Committee code reviews include screening for clinical issues prior to the event that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Quality Work Group meet monthly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all surgical deaths with identified problems or opportunities for improvement are reviewed by the Morbidity and Mortality Committee.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Environment of Care Board minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the surveillance monitoring systems on the locked mental health units at the York campus are functional and that regular inspections are documented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that chemicals stored on the dialysis unit at the Nashville campus are secured at all times and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the negative pressure control systems in the post-anesthesia care unit isolation rooms at both campuses are functional and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a laser warning sign be posted on the door in the eye clinic laser room at the York campus and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that providers complete and document patient discharge instructions and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that stroke guidelines be posted on the intensive care and inpatient medical units.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
Combined Assessment Program Review of the Alexandria VA Health Care System, Pineville, Louisiana
|
14-02070-305

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2015
We recommended that processes be strengthened to ensure that the Inpatient Management Committee reviews each code episode and that code data is collected.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2015
We recommended that the Surgical Review Committee document its review of National Surgical Office reports and monitoring of surgery performance improvement activities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2015
We recommended that processes be strengthened to ensure that the Blood Usage, Surgical, and Other Invasive Procedures Review Committee members from Medicine, Surgery, and Anesthesia Services consistently attend meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that processes be strengthened to ensure that patient care areas are clean and in good repair and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that processes be strengthened to ensure that public restrooms are clean and in good repair and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that processes be strengthened to ensure that all designated same day surgery and eye clinic employees receive laser safety training in accordance with facility policy and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that the facility¿s stroke policy be revised to address the difference in approach to patients presenting with symptoms within the facility's defined timeframe to be eligible for tissue plasminogen activator and those presenting outside the defined timeframe and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2016
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2016
We recommended that the facility collect and report to VHA and the Executive Committee of the Medical Staff the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that the facility offer restorative nursing services and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2015
We recommended that processes be strengthened to ensure that emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2015
We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the facility designate Level 1 ancillary staff, that processes be strengthened to ensure that Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training, and that compliance with training be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that appropriate signage be in place to identify magnetic resonance imaging Zones III and IV.
Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California
|
14-02071-02

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2015
We recommended that processes be strengthened to ensure that the Resuscitation Services Committee reviews each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that processes be strengthened to ensure that Environment of Care Committee minutes and the environment of care rounds database accurately reflect whether deficiencies were resolved.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that patient care areas and public restrooms are clean and free from offensive odors and walls, counters, floors, and furnishings in these areas are in good repair and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that equipment items receive appropriate maintenance and preventive maintenance and electrical inspections stickers are current and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and medications are secured at all times and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake and that patients are provided with printed stroke education upon discharge and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that the facility collect and report to the Medical Executive Committee the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that processes be strengthened to ensure that staff include restorative nursing goals and interventions in residents’ care plans and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that processes be strengthened to ensure that staff complete required restorative nursing interventions and document the interventions with the frequency established by facility policy, that documentation reflects progress toward goals and reasons why interventions were not provided, and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and are signed and dated by a Level 2 magnetic resonance imaging personnel prior to the scan and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2014
We recommended that facility policy be revised to correct contradictory elements and to be consistent with VHA policy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted to determine the risk of tuberculosis transmission to contractors.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that construction site inspections are conducted at the required frequency and that inspections contain all elements required by VHA policy.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all construction projects comply with VHA policy requirements.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania
|
14-00925-299

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the parent facility includes staff at the Northampton County and Williamsport CBOCs in required education, training, planning, and participation in annual disaster exercises.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the parent facility documents Emergency Management Preparedness-specific training completed for the Northampton County and Williamsport CBOCs' clinical providers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the parent facility's Emergency Management Committee evaluates the Northampton County and Williamsport CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer offurther treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2015
We recommended that staff provide medication counseling/education as required.
Combined Assessment Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas
|
14-02064-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Medical Executive Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and consistently document its review of National Surgical Office reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data from electronic health record quality reviews are analyzed at least quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Tissue and Transfusion Committee member from Anesthesia Service consistently attends meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that damaged optical examination chairs in the eye clinics are repaired or removed from service.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to VHA the percent of patients with stroke symptoms who had the stroke scale completed and the percent of patients screened for difficulty swallowing before oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that appropriate signage and barriers be in place at the Leavenworth division to restrict access to magnetic resonance imaging Zone III.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Magnetic Resonance Imaging Safety Committee and the Patient Safety Manager evaluate the identified potential safety and security risks and take appropriate actions.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Long Beach Healthcare System, Long Beach, California
|
14-00927-293

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that panic alarms are tested, and testing is documented at the Santa Ana CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the parent facility's Emergency Management Committee evaluate emergency preparedness activities, participation in annual disaster exercise, and staff training/education related to emergency preparedness requirements at the Santa Ana CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that staff document that medication reconciliation is completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that staff provide medication counseling/education as required.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bath VA Medical Center, Bath, New York
|
14-00928-291

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers complete required training within 12 months of appointment to Patient Aligned Care Teams.
Combined Assessment Program Review of the Bath VA Medical Center, Bath, New York
|
14-02075-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that the Morbidity and Mortality Committee review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the facility consistently collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Tennessee Valley Healthcare System, Nashville, Tennessee
|
14-00929-287

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that the CBOC is Americans with Disabilities Act accessible at the Maury County CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that managers ensure staff can access the electronic version of hazardous materials information at the Maury County CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that processes are improved to ensure the tracking of hazardous materials at the Maury County CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that the effectiveness of the panic alarm system is evaluated at the Maury County CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that signage is installed at the Maury County CBOC to clearly identify the location of fire all extinguishers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that medications are secured and accessible only by individuals who either dispense or administer medications at the Maury County CBOC, and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Maury County CBOC to the parent facility.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that that that the information technology server closet at the Maury County CBOC is maintained according to information technology safety and security standards.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that CBOC and Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that staff consistently provide patients with medication counseling and written medication information that includes the fluoroquinolone.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
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