Date Issued
|
Report Number
14-01504-32
All Reports
Date Issued
|
Report Number
14-00937-31
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
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
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
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
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
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
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
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
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that staff provide and document medication counseling/education as required.
Date Issued
|
Report Number
14-02084-16
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that the Surgical Work Group meet monthly.
No. 5
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
14-00939-27
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
14-02577-07
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to review the 206 temporary 100 percent disability evaluation claims remaining from our inspection universe and take appropriate actions.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level Special Monthly Compensation and Ancillary Benefits.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure Systematic Analysis of Operations contain thorough analyses, use appropriate data, and include all recommendations needed, along with time frames for implementation.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Date Issued
|
Report Number
14-03298-20
Date Issued
|
Report Number
13-02527-23
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/23/2015
We recommended that the Facility Director conduct and document a review to evaluate patient rounds and documentation policies.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/23/2015
We recommended that the Facility Director educate and train all staff regarding patient rounds policies.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/23/2015
We recommended that the Facility Director consult with Regional Counsel regarding institutional disclosure to the patient’s next-of-kin in accordance with VHA Handbook 1004.08.
Date Issued
|
Report Number
14-02076-13
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
14-02074-06
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Quality, Safety, and Value Council meet monthly.
No. 2
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
14-01261-03
Date Issued
|
Report Number
14-02077-01
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
to Veterans Health Administration (VHA)
We recommended that the Surgical Quality Work Group meet monthly.
No. 5
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
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
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
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
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
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
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
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
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
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
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
to Veterans Health Administration (VHA)
We recommended that stroke guidelines be posted on the intensive care and inpatient medical units.
No. 17
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
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
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
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.
Date Issued
|
Report Number
14-02070-305
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
14-02071-02
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all construction projects comply with VHA policy requirements.
Date Issued
|
Report Number
14-02100-271
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2015
We recommended the Portland VA Regional Office Director implement a plan to ensure staff timely process rating reductions for temporary 100 percent disability evaluations.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2015
We recommended the Portland VA Regional Office Director conduct a review of the 364 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2015
We recommended the Portland VA Regional Office Director assess the effectiveness of training for special monthly compensation and ancillary benefits claims.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 5/28/2015
We recommended the Under Secretary for Benefits implement a national plan for an additional level of review for special monthly compensation and ancillary benefits claims.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2015
We recommended the Portland VA Regional Office Director implement a plan, and assess the effectiveness of the plan, to ensure adequate and continuous oversight of completing Systematic Analyses of Operations.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2015
We recommended the Portland VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Date Issued
|
Report Number
14-01688-303
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommended the Salt Lake City VA Regional Office Director develop and implement a plan to ensure staff take timely and appropriate action on reminder notifications for medical reexaminations.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommended the Salt Lake City VA Regional Office Director develop and implement a plan to review for accuracy the 135 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommended the Salt Lake City VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommended the Salt Lake City VA Regional Office Director amend the local workload management plan to ensure timeliness standards for processing benefits reduction workloads consistent with Veterans Benefits Administration policy.
Date Issued
|
Report Number
14-00925-299
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
to Veterans Health Administration (VHA)
Closure Date: 7/8/2015
We recommended that staff provide medication counseling/education as required.
Date Issued
|
Report Number
14-03212-295
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that the Eastern Kansas Health Care System Director ensure that all patients who present to the Eastern Kansas Health Care System Emergency Department requesting an examination or treatment receive a medical screening examination and that compliance is monitored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that the Eastern Kansas Health Care System Director ensure Leavenworth VAMC Emergency Department and Primary Care Clinic nursing staff document required assessments and that compliance is monitored.
Date Issued
|
Report Number
14-02064-252
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
to Veterans Health Administration (VHA)
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Medical Executive Committee.
No. 3
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
13-04005-296
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that the facility’s out of operating room airway management policy is updated to include all Veterans Health Administration requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/21/2015
We recommended that the Facility Director ensure that processes be strengthened to complete out of operating room airway management training and competency requirements as outlined by Veterans Health Administration and local policies.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that processes be strengthened to provide out of operating room airway management coverage as required.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that highly portable video laryngoscope equipment is immediately available
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that analysis of the five patient care events identified in this report is completed as required.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that the scopes of practice are updated for non-licensed independent practitioners who perform out of operating room airway management.
Date Issued
|
Report Number
14-00927-293
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that staff provide medication counseling/education as required.