All Reports

Combined Assessment Program Review of the Central Alabama Veterans Health Care System, Montgomery, Alabama
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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.
Healthcare Inspection – Radiology Scheduling and Other Administrative Issues, VA Loma Linda Healthcare System, Loma Linda, California
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14-00661-43

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015
We recommended that the Facility Director strengthen processes to ensure that patients are involved in the scheduling process, that program managers periodically monitor exam cancelations, and that staff accurately document patient dispositions and actions taken related to patient scheduling.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that the Facility Director ensure that clinicians review the electronic health records of the two patients who had unfulfilled computed tomography orders to determine whether follow-up actions are needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that the Facility Director monitor compliance with the facility's newly implemented scheduling policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director ensure that proper equipment and software is available for uploading non-VA images and that staff are trained.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director ensure that program managers periodically assess and monitor the appropriateness of early walk-in ultrasound clinic closure and take necessary steps to ensure outpatients receive timely studies.
Combined Assessment Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
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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.
Review of Alleged Mismanagement of VA's Office of Public and Intergovernmental Affairs Outreach Contracts
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13-01545-11

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs limit future use of time and materials contracts to those instances where the extent or duration of the work cannot be anticipated with any reasonable degree of confidence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that significant new contract requirements are solicited in lieu of merely modifying existing contracts to meet new needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that contractor billings are approved based on sufficient documentation to demonstrate that contractors are meeting performance-based requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs implement improved oversight of contractor activities to ensure they are appropriate to meet contract terms and do not include inherently Governmental functions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs develop and implement program performance metrics to determine whether outreach and awareness campaigns are improving veterans’ awareness of and access to VA services and benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,000,000.00
Audit of VHA's Support Service Contracts
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12-02576-30

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health implement a quality assurance program that provides sufficient oversight to ensure that contracting issues are corrected by the responsible contracting office.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health implement a mechanism to facilitate and ensure contracting officers’ performance can be objectively evaluated against their performance standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health monitor contracting officer performance deficiencies and ensure training is provided to correct identified deficiencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health ensure contracting staff complete Integrated Oversight Process reviews in accordance with established policies and contracting officers’ performance standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2016
We recommended the Interim Under Secretary for Health revise Integrated Oversight Process review procedures to include a review to ensure Advisory and Assistance services are identified and approved.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended the Interim Under Secretary for Health ensure that contracting officers delegate in writing contracting officers’ representatives requirements and authorities to monitor contracts, as required by Federal and VA acquisition policy and contracting officers’ performance standards.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended the Interim Under Secretary for Health ensure that contracting officers conduct and document quarterly meetings with contracting officers’ representatives as required by VA acquisition policy.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 795,000,000.00
Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota
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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.
Inspection of VA Regional Office Huntington, West Virginia
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14-02101-09

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director develop and implement a plan to review for accuracy the 138 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on identifying and returning insufficient medical examination reports related to traumatic brain injury claims to medical facilities for correction.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration’s second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing these claims to identify local training needs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Huntington VA regional Office Director develops and implements a plan to ensure staff complies with local second-signature requirements for processing special monthly compensation.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans
Healthcare Inspection – Quality and Coordination of Care Concerns at Three Veterans Integrated Service Network 11 Facilities
|
14-01519-40

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible institutional disclosure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended the Network Director conduct a thorough review of the Northern Indiana Health Care System Mental Health Service’s processes and leadership.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure providers’ electronic health record documentation is consistent with VHA Handbook 1907.01, Health Information Management and Health Records, especially in regards to discharge instructions and summaries, patient problem lists, and critical telephone and fax communications, as discussed in this report.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director ensure that Northern Indiana Health Care System Non-VA Care Coordination staff case manage patients consistent with their current functional statements or that the role of Non-VA Care Coordination staff be reassessed and functional statements changed to reflect tasks actually performed by the Non-VA Care Coordination staff.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director ensure that all Northern Indiana Health Care System providers receive ongoing professional practice evaluations consistent with VHA Directive 1100.19, Credentialing and Privileging.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that responsible clinical staff review the patient’s electronic health record and initiate appropriate follow-up action consistent with VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, when a patient is a “no show.”
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that the Northern Indiana Health Care System Director develop guidelines for documenting and responding to secure messages.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that Northern Indiana Health Care System mental health patients be assigned a Mental Health Treatment Coordinator and that a process is in place to reassign coordinators in the event of staff departure consistent with the Deputy Undersecretary for Health for Operations and Management’s “Assignment of the Mental Health Treatment Coordinator” and local policy requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that Northern Indiana Health Care System Community Based Outpatient Clinic mental health services are provided consistent with VHA Directive 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure processes are in place at the Northern Indiana Health Care System to ensure continuity of mental health care in the event of staff departure and/or reassignment.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director ensure Northern Indiana Health Care System telephone triage, suicide prevention program, and emergency department staff receive training regarding expected psychiatric emergency response.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure Northern Indiana Health Care System providers implement stepped consultative care and integrate behavioral health with the primary care of chronic pain consistent with VHA Directive 2009-053, Pain Management.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that Richard L. Roudebush VA Medical Center Clinical Application Coordinators remove Computerized Patient Record System consult order templates from facility ordering systems when a consult service is no longer offered.
Inspection of VA Regional Office Providence, Rhode Island
|
13-03221-08

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director conduct a review of the 70 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director provide oversight to ensure staff follows Veterans Benefits Administration guidance related to processing reminder notifications for medical reexaminations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/16/2015
We recommended the Providence VA Regional Office Director ensure staff receive refresher training on proper evaluation of traumatic brain injury and special monthly compensation and ancillary benefits claims and implement plans to ensure the effectiveness of that training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director develop and implement a plan to ensure timely completion of Systematic Analyses of Operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff takes timely action on claims requiring rating decisions for reduction of benefits.
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.
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 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.
Inspection of VA Regional Office Buffalo, New York
|
14-02577-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Alleged Nursing Deficiencies Led to Patient's Death, Hampton VA Medical Center, Hampton, Virginia
|
13-02527-23

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas
|
14-02076-13

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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

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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

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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 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.
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