Date Issued
|
Report Number
09-01858-233
All Reports
Date Issued
|
Report Number
11-01057-241
Date Issued
|
Report Number
11-01025-242
Date Issued
|
Report Number
15-00347-154
Date Issued
|
Report Number
15-00030-202
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the Medical Executive Committee review privilege forms annually and document the review.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility secure sterile supply cabinets when not in use and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility promptly remove outdated commercial supplies from examination rooms and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that facility managers ensure employees lock computers and secure sensitive patient information when they leave the area and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility collect and report to the Veterans Health Administration 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
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that facility managers ensure that intensive care unit, Emergency Department, and medical/surgical unit (4A) employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and completed and documented.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed and documented for employees on the intensive care unit.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor competency.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 1/4/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and includes all required elements and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the facility correct the identified deficiencies in the domiciliary and that documentation reflect correction.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that domiciliary program managers ensure residents secure medications in their rooms and monitor compliance.
Date Issued
|
Report Number
15-00121-201
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that a functional panic alarm system is installed at the Jay CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
|
Report Number
14-03651-203
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/16/2016
We recommended the Under Secretary for Benefits convene an Administrative Investigation Board to determine if VA Regional Office management intentionally misapplied the guidance as a means to remove aging claims from its inventory.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/20/2016
We recommended the Under Secretary for Benefits review leadership performance and restore accountability for completing work requirements in accordance with Veterans Benefits Administration policy.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 6/16/2016
We recommended the Philadelphia VA Regional Office Director implement a plan to ensure staff follow the standardized checklist when conducting and entering internal quality reviews results.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 6/16/2016
We recommended the Philadelphia VA Regional Office Director take appropriate administrative action to hold staff accountable for altering quality review results.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 6/16/2016
We recommended the Philadelphia VA Regional Office Director conduct a review of the 52 altered quality reviews to determine if the altered results affected veterans' benefits or an individual's performance and take corrective actions as required.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Philadelphia VA Regional Office implement a plan to ensure and effectively monitor staff enter appealed claims in Veterans Appeals Control and Locator System within 7 days to ensure accurate and timely reporting to stakeholders.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Philadelphia VA Regional Office Director implement a plan to ensure efficient operations when processing appealed claims, to include determining if additional staffing is required to process approximately 700 appealed claims from another VA Regional Office.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits implement a contingency plan to address backlogged inquiries received through the Inquiry Routing and Information System to ensure timely responses are provided to veterans and their families.
No. 9
to Veterans Benefits Administration (VBA)
Closure Date: 6/11/2015
We recommended the Under Secretary for Benefits clarify timeliness goals for responding to inquiries received through the Inquiry Routing and Information System.
No. 10
to Veterans Benefits Administration (VBA)
Closure Date: 6/16/2016
We recommended the Under Secretary for Benefits modify performance measures to include the number of pending electronic inquiries awaiting responses from VA Regional Office staff.
No. 11
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Philadelphia VA Regional Office Director ensure supervisory staff receive refresher training on records management disposition.
No. 12
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Philadelphia VA Regional Office Director implement a plan that includes periodic reviews of records maintained by supervisory staff to ensure records are disposed of according to the records control schedule.
No. 13
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits establish policies and procedures to standardize procedures for merging duplicate records that includes timeliness goals and oversight responsibility.
No. 14
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Philadelphia VA Regional Office Director take immediate action to merge the 248 duplicate records identified during our review and take timely action to terminate any improper payments associated with those records.
No. 15
to Veterans Benefits Administration (VBA)
Closure Date: 6/16/2016
We recommended the Under Secretary for Benefits develop and implement a plan to routinely provide VA Regional Office staff a listing of duplicate records and payment information so timely, corrective actions can be taken to merge the records and terminate improper payments.
No. 16
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits clarify policies and procedures related to recouping improper payments resulting from duplicate records.
No. 17
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits revise policies and procedures to emphasize VA Regional Offices must minimize the number of date stamps issued, limit use of date stamps to authorized staff, and control date stamp keys as measures to prevent and deter potential fraudulent activity.
No. 18
to Veterans Benefits Administration (VBA)
Closure Date: 6/11/2015
We recommended the Under Secretary for Benefits direct the Philadelphia VA Regional Office Director ensure staff process all mail concerning beneficiaries in the mailroom within 6 hours of receipt.
No. 19
to Veterans Benefits Administration (VBA)
Closure Date: 3/21/2016
We recommended the Under Secretary for Benefits initiate independent, unannounced reviews of the Philadelphia VA Regional Office to ensure staff process mail within 6 hours of receiving the mail.
No. 20
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits develop and implement a plan to ensure VA Regional Office staff prioritize scanning documents to the Veterans Benefits Administration's electronic repository to ensure the documents are timely associated with electronic claims folders.
No. 21
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Under Secretary for Benefits develop and implement a timeliness goal for scanning and uploading documents to the Veterans Benefits Administration's electronic repository.
No. 22
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits examine the effectiveness of Pension and Fiduciary Services' strategies for following up and closing out recommendations for improvement resulting from site visits.
No. 23
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits develop and implement a plan to ensure Philadelphia VA Regional Office staff take action to process its backlog of returned mail.
No. 24
to Veterans Benefits Administration (VBA)
Closure Date: 5/17/2018
We recommended the Under Secretary for Benefits develop and implement a timeliness goal for VARO Offices to process returned mail.
No. 25
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits implement procedures to ensure the improvement actions identified and recommended by VBA's internal review teams are appropriately addressed.
No. 26
to Veterans Benefits Administration (VBA)
Closure Date: 9/6/2016
We recommended the Under Secretary for Benefits develop and implement standardized procedures that includes an audit trail for the destruction of military file mail.
No. 27
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Under Secretary for Benefits develop and implement a plan to conduct routine accuracy reviews of mail categorized as military file mail prior to destruction.
No. 28
to Veterans Benefits Administration (VBA)
Closure Date: 3/21/2016
We recommended the Under Secretary for Benefits conduct an independent review of all military file mail pending destruction at the Philadelphia VA Regional Office.
No. 29
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Philadelphia VA Regional Office Director ensure claims processing staff at the Philadelphia Pension Management Center receive refresher training on identifying and processing military file mail.
No. 30
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits develop and implement a plan to ensure Philadelphia VA Regional Office staff associate the remaining backlog of drop mail with veterans' claims.
No. 31
to Veterans Benefits Administration (VBA)
Closure Date: 10/2/2017
We recommended the Under Secretary for Benefits develop and implement a plan that includes a timeliness goal to ensure mail is associated with electronic or paper claims folders prior to claims processing actions.
No. 32
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Philadelphia VA Regional Office Director develop a plan that includes routine supervisory reviews of all space accessible by VA Regional Office staff as a measure to prevent improper storage of documents containing personally identifiable data.
No. 33
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Under Secretary for Benefits take immediate action to ensure Veterans Benefits Administration workspace complies with VA Occupational Safety and Health requirements contained in Federal laws, regulations, and executive orders.
No. 34
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2015
We recommended the Philadelphia VA Regional Office Director ensure veterans' records and VA equipment are adequately safeguarded.
No. 35
to Veterans Benefits Administration (VBA)
Closure Date: 7/25/2018
We recommend the Under Secretary for Benefits conduct an independent review of production standards for the Pension Call Center staff to determine if the timeliness standard is
reasonable and obtainable without comprising the quality of customer service to callers.
Date Issued
|
Report Number
15-01332-121
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/15/2015
We recommended the Under Secretary for Benefits implement a plan to ensure only specifically authorized staff at the Boston VA Regional Office use date stamping equipment.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/29/2015
We recommended the Under Secretary for Benefits implement a plan to ensure claims processing staff at the Boston VA Regional Office receive training on securing date stamping equipment.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/15/2015
We recommended the Under Secretary for Benefits implement a plan to ensure staff at the Boston VA Regional Office secure the keys needed to open and operate date stamping equipment.
Date Issued
|
Report Number
14-03824-155
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the System Director ensure that patient aligned care team provider staffing is adequate to provide patients with timely access to care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the System Director ensure that a contingency plan for patient aligned care team provider shortages is developed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the System Director ensure that patient aligned care team cancellations and other data are monitored to determine when there is a need to activate a contingency plan.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the System Director ensure that staff comply with local and national policies on contacting patients when scheduling mental health services.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the System Director ensure that policy requirements for discontinuation of mental health consultation are clear and that staff comply with those requirements.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/17/2017
We recommended that the System Director ensure that the Access Action Plan for Orthopedic Surgery Services is carried out in an effort to improve access to orthopedic surgical services.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the System Director ensure that providers comply with their responsibilities of electronic health record documentation of the community care of co-managed patients.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/14/2016
We recommended that the System Director ensure compliance with local policy requiring that community health care records be scanned into the electronic health records of co-managed patients.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that the System Director ensure that the local outpatient tube-feeding policy and practice comply with Veterans Health Administration requirements.
Date Issued
|
Report Number
13-01730-159
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of the Secretary (SVA)
Closure Date: 5/16/2016
We recommend that the VA Chief of Staff (COS) confer with the Offices of Human Resources (OHR), General Counsel (OGC), and Accountability Review (OAR) to determine the appropriate administrative action to take, if any, against the OIT employees involved in this particular matter.
No. 2
to Office of the Secretary (SVA)
Closure Date: 9/1/2015
We recommend that the COS confer with OGC and the Executive Director of the Office of Acquisition Operations (OAO) to determine the appropriate action to take against Systems Made Simple, Inc., for contractor employees failing to adhere to VA information security policies and contract security requirements.
No. 3
to Office of the Secretary (SVA)
Closure Date: 5/16/2016
We recommend that the COS ensure that VA's information security policies are thoroughly reviewed and rewritten to address any weaknesses.
No. 4
to Office of the Secretary (SVA)
Closure Date: 1/11/2016
We recommend that the COS ensure that VA's information security training is thoroughly reviewed and rewritten to address any weaknesses.
Date Issued
|
Report Number
15-00073-200
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Special Care Unit Committee review each code episode.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Surgical Quality Council meet monthly and document its review of National Surgical Office reports.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Surgical Quality Council review all surgical deaths with identified problems or opportunities for improvement.
No. 4
to Veterans Health Administration (VHA)
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
We recommended that the facility use special medication labeling and unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
No. 8
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended 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 facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
We recommended that facility managers revise local policies to require that radiology interpretation and computerized tomography coverage be available on call within 30 minutes.
No. 13
to Veterans Health Administration (VHA)
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
No. 14
to Veterans Health Administration (VHA)
We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.
No. 15
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that monthly inspections of the Mental Health Residential Rehabilitation Treatment Programs include all required elements.
No. 16
to Veterans Health Administration (VHA)
We recommended that Mental Health Residential Rehabilitation Treatment Program managers ensure that the programs have written agreements in place acknowledging resident responsibility for medication security.
Date Issued
|
Report Number
15-00069-199
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that when conversions from observation bed status to acute admissions are 25–30 percent or more, the facility reassess observation criteria and utilization.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the Surgical Work Group include the Chief of Staff as a member.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the Safe Patient Handling Committee track patient handling injury data.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended the facility ensure a third party conducts quality assurance reviews on a sample of the scanned documents.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that Environment of Care Board and Safety Committee minutes include corrective actions to address identified deficiencies and track those actions to closure.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that facility managers ensure community living center treatment carts containing resident care supplies are clean and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure critical medical equipment in the community living center is plugged into outlets that function in the event of a power loss and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that nursing reviewers sign the monthly medication review forms and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the facility’s recently chartered Consult Management Committee meet regularly and document oversight of consult management.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that Level 2 magnetic resonance imaging personnel review and sign secondary patient safety screening forms prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended 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 facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements and that facility managers monitor compliance.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure the American Lake division follows local emergency airway management policy, or if the facility plans to perform intubations in areas designated to call 911, the facility updates the local emergency airway management policy and ensures privileged providers or clinicians with emergency airway management scope of practice are available.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure reporting of emergency airway management data to the designated committee with the frequency required by local policy.
Date Issued
|
Report Number
15-00072-160
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the Environment of Care Committee gather, track, and share patient handling injury data.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the facility conduct contrast reaction drills in magnetic resonance imaging and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility ensure all designated Level 1 ancillary staff and all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the facility collect and report to the Veterans Health Administration 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: 10/19/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility mangers monitor compliance.
Date Issued
|
Report Number
15-00071-158
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that facility managers ensure that emergency airway management privileges granted are appropriate for the practitioners' skills and training.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the Cardiopulmonary Resuscitation Committee review 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. 3
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document did not meet image quality controls and a correction process if scanned items have errors.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that Environment of Care Committee minutes include consistent discussion of rounds deficiencies, trends, and actions and tracking of actions to closure.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that infection prevention and control meeting minutes consistently reflect discussion of identified high-risk priority areas.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that facility managers ensure patient care areas and public restrooms are clean and toilet paper dispensers are in good repair and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility secure medication carts when not in use and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility update the local consult policy for policy changes and review the policy at least every 3 years and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility conduct contrast reaction and fire emergency drills in magnetic resonance imaging and that the facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended that the facility conduct initial patient safety screenings and that the facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended 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 the facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility report to the Veterans Health Administration 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)
Closure Date: 5/13/2016
We recommended that facility managers ensure that all nursing employees who perform 12-lead electrocardiograms have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the 2B-ICU.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility revise the emergency airway management policy to include a specific plan to manage difficult airways.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements, including a written test, and that facility managers monitor compliance.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
Date Issued
|
Report Number
14-03927-197
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that the Facility Director ensure that the appropriateness of assigning patients to telemetry is reviewed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that the Facility Director ensure dedicated wireless telephones are continuously carried by unit charge nurses or designees for effective communication between unit and telemetry monitoring technicians as required by local policy.
Date Issued
|
Report Number
15-00108-194
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/15/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fort Detrick CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that employees at the Fort Detrick CBOC receive the required training on hazardous materials.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that personal protective equipment is available for all staff at the Fort Detrick CBOC.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that staff protect patient-identifiable information on laboratory specimens at the Fort Detrick CBOC.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that the information technology server closet at the Fort Detrick CBOC is maintained according to information technology safety and security standards.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within the time frame specified in VHA policy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/15/2016
We recommended that all providers and clinical associates in the outpatient clinics receive health coaching training within the time frame specified in VHA policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
|
Report Number
14-04391-162
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Jackson VA Outpatient Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that employees at the Jackson VA Outpatient Clinic receive the required training on hazardous materials.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Jackson VA Outpatient Clinic.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that fire drills are performed every 12 months at the Jackson VA Outpatient Clinic.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that the information technology server closet at the Jackson VA Outpatient Clinic is maintained according to information technology safety and security standards.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
We recommended that the staff at the Jackson VA Outpatient Clinic receive regular information/updates on their responsibilities in emergency response operations.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
We recommended that the staff at the Jackson VA Outpatient Clinic participate in scheduled emergency management training and exercises.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that 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: 8/17/2015
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
|
Report Number
15-00113-161
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Delray Beach, FL, CBOC and that compliance is monitored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that patient-identifiable information on laboratory specimens is protected during transport from the Delray Beach, FL, CBOC to the parent facility.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Delray Beach, FL, CBOC.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/20/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
|
Report Number
14-02139-156
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that contracted providers in all patient care areas complete the Veterans Health Administration’s suicide risk management training.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure development of a process to measure the effectiveness of Veterans Health Administration required suicide risk management training for all staff members who have completed it and to provide remedial training when needed.
Date Issued
|
Report Number
15-01809-163
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians provide and document discharge instructions for all identified needs and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reassess patients¿ learning needs prior to providing important instructions, including discharge instructions, and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reconcile conflicting needs and instructions before discharging patients and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that patients receive ordered post-discharge referrals and that facility managers monitor compliance.