Date Issued
|
Report Number
14-01072-140
All Reports
Date Issued
|
Report Number
14-01073-139
Date Issued
|
Report Number
14-01288-145
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that inspections are completed at the designated frequency and by required members, that all required elements are documented, and that construction sites comply with applicable VA and Occupational Safety and Health Administration requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that contractor tuberculosis risk assessments are conducted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that facilities establish Construction Safety Committees; develop and implement written policies addressing committee responsibilities; assure required committee membership and participation; and ensure meeting minutes include consistent documentation of inspection results, follow-up actions to resolve unsafe conditions, and tracking of actions to completion.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/27/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that Infection Control Committee meeting minutes include consistent documentation of construction-related infection control surveillance activities and any necessary follow-up actions to identified trends or problems.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that designated facility staff receive required initial and biennial construction safety training.
Date Issued
|
Report Number
13-00589-137
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Under Secretary for Health establish a process to track VA medical facilities' expenditure of NRM funds toward addressing the maintenance backlog.
No. 2
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Under Secretary for Health establish procedures to ensure VA medical facilities projects address the Facility Condition Assessment deficiencies as approved under the Strategic Capital Investment Plan.
No. 3
to Office of Management (OM)
Closure Date: 5/20/2015
We recommend the Under Secretary for Health establish procedures to identify non-recurring maintenance projects that are not meeting milestones to ensure that timely corrective actions are taken.
No. 4
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Under Secretary for Health develop clearly defined criteria for assigning risk levels to building infrastructure systems reviewed by Facility Condition Assessment contractors.
No. 5
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer increase financial accountability by implementing standardized accounting procedures for tracking NRM projects' financial performance.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/15/2014
We recommend the Principal Executive Director, Office of Acquisition, Logistics and Construction instruct contract engineers to assign risk levels to identified maintenance deficiencies based on VHA criteria.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/15/2014
We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction review Facility Condition Assessment estimating processes and procedures to ensure compliance with industry best practices.
No. 8
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/15/2014
We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction review historical project costs to determine an effective adjustment factor to better estimate contract costs to complete the repair of identified maintenance deficiencies.
Date Issued
|
Report Number
14-00689-142
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are completed within the timeframe required by facility bylaws.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that EOC Committee and Administrative Executive Committee minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that medication/supply carts are secured at all times and that compliance be monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that Nursing Service is represented at Radiation Safety Committee meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that managers initiate timely actions to address deficiencies identified during annual physical security surveys.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that pharmacy inspections are consistently completed on the same day they were initiated and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections, daily public area inspections and bed checks, and weekly contraband inspections are completed and documented and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that medications in resident rooms on the MH RRTP units are secured and daily inspections for this are documented and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that written agreements acknowledging MH RRTP resident responsibility for medication security are documented and that compliance be monitored.
Date Issued
|
Report Number
13-01819-133
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the Under Secretary for Health develop and implement a plan of action to ensure that VA purchase of medical services from affiliated academic institutions is in compliance with VA Directive 1663 and procurement laws and regulations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the Under Secretary for Health ensure that VA prohibits the use of purchase orders to obtain contract provider services unless the purchase orders contain the required clauses identified in the report.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that the Veterans Integrated Service Network Director ensure that the procurement of specialized medical services is in accordance with VA Directive 1663.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the Veterans Integrated Service Network Director ensure that Interim Contract Authority is appropriately granted and used as outlined in VA Directive 1663.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the VA Salt Lake City Health Care System Director develop and implement as necessary an alternate source plan for the provision of anesthesiology services that complies with VA Directive 1663.
Date Issued
|
Report Number
14-01104-134
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/1/2014
We recommended that the Facility Director ensure that action plans are developed and implemented to facilitate meeting and maintaining the facility's target of not more than 10 percent of emergency department patients should experience a length of stay exceeding 6 hours.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that the Facility Director ensure that nursing staff reassess emergency department patients according to facility policy.
Date Issued
|
Report Number
14-00227-131
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
to Veterans Health Administration (VHA)
We recommended that staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 4
to Veterans Health Administration (VHA)
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. 5
to Veterans Health Administration (VHA)
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 6
to Veterans Health Administration (VHA)
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Date Issued
|
Report Number
14-00684-132
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the MEC discuss and document its approval of the use of another facility's physicians for teledermatology services.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that the facility obtain teledermatology physicians' professional practice evaluation information from the providing facility.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
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. 5
to Veterans Health Administration (VHA)
Closure Date: 10/31/2014
We recommended that processes be strengthened to ensure that the Acute Care Committee reviews each code episode and that code reviews consistently include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that the recipient list for the automated e-mail notification for the patient incident reporting process is kept current.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that processes be strengthened to ensure that a member from Anesthesia Service attends Transfusion Utilization Committee meetings and that the blood/transfusions usage review process consistently includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that the facility comply with VHA and local smoking policies and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that the VISN 11 Director establish a non-facility team to conduct a comprehensive EOC evaluation of the facility and ensure that deficiencies are corrected and that an action plan is developed to ensure the facility is properly cleaned and maintained.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the facility establish a policy for equipment inspection and testing and that compliance with the newly established policy be monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that signs be posted in waiting and procedure rooms within radiology asking female patients to notify staff if they may be pregnant.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that processes be strengthened to ensure that expired medications are removed from radiology crash carts and clinical staff are trained on how to locate the crash cart expiration date and that compliance be monitored.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on identifying and correcting environmental hazards, content and proper use of the MH EOC Checklist, and VA¿s National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the facility establish an interprofessional pressure ulcer committee.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 10/31/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 10/31/2014
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Date Issued
|
Report Number
14-00240-129
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Casa Grande CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/13/2015
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Casa Grande, Green Valley, and Safford CBOCs.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/13/2015
We recommended that the information technology server closets at the Green Valley and Safford CBOCs are maintained according to information technology safety and security standards.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/13/2015
We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/8/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coach training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Date Issued
|
Report Number
14-00241-128
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that external signage clearly identifies the building as a VA CBOC at the Eastside El Paso CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/22/2015
We recommended that testing of the panic alarm system is documented at the Eastside El Paso CBOC.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/22/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended that staff document the evaluation of patient¿s level of understanding for the medication education.
Date Issued
|
Report Number
14-00683-130
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that results of completed FPPEs for newly hired licensed independent practitioners are consistently reported to the MEC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that Transfusion Committee members from Surgery and Anesthesia Services consistently attend meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/9/2015
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated after initial use and that compliance be monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff, ISIT members, and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing includes VA Police response time and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that MH EOC Checklist inspections include participation by all required ISIT members and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that the ISIT assigns a risk level per identified deficiency at the time of acute MH unit inspections and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that nursing managers implement VHA's staffing methodology.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/9/2015
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections and daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that all designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings and that compliance be monitored.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that staff do not provide medical treatments to residents during meals in the common dining area.
Date Issued
|
Report Number
14-00239-127
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that Community Based Outpatient Clinic/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that Community Based Outpatient Clinic/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. 3
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that clinical executive/primary care leaders ensure that Community Based Outpatient Clinic/Primary Care Clinic Designated Women’s Health Providers maintain proficiency as required for the provision of women’s health care.
Date Issued
|
Report Number
13-02267-124
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/29/2015
We recommend the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 to identify unauthorized commitments, and submit ratification requests for the unauthorized commitments identified by the Office of Inspector General and by Veterans Integrated Service Network 7 to the Veterans Health Administration Head of Contracting Activity.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/29/2015
We recommended the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high-risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 for purchases lacking sufficient documentation and take steps to recover identified inappropriate payments.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/23/2014
We recommended the Veterans Integrated Service Network 7 Director develop monitoring mechanisms to ensure Charleston VA Medical Center Engineering Service approving officials consistently use Veterans Health Administration’s required Approving Official Checklist to identify split purchases, purchases that exceed the micro-purchase limit for services, and purchases without sufficient documentation.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/23/2014
We recommended the Veterans Integrated Service Network 7 Director ensure Charleston VA Medical Center Engineering Service’s purchase cardholders and approving officials receive required refresher training every 2 years.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 646,000.00
Date Issued
|
Report Number
14-00307-126
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the MEC document discussion of PRC quarterly summary reports.
No. 2
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the MEC.
No. 3
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with the new observation bed policy.
No. 4
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data about observation bed use continues to be gathered.
No. 5
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of the patients in acute beds.
No. 6
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode, that code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code, and that code data is collected.
No. 7
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and document its review of required monthly and quarterly performance data elements, including local performance data and National Surgical Office reports.
No. 8
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 9
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 10
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that members from Medicine, Surgery, and Anesthesia Services attend Transfusion Process Committee meetings and that the blood/transfusions usage review process includes the results of proficiency testing.
No. 11
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Infection Control Committee minutes reflect follow-up on actions that were implemented to address identified problems.
No. 12
to Veterans Health Administration (VHA)
We recommended that nursing managers continue to monitor the staffing methodology that was implemented in November 2012.
No. 13
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with the revised pressure ulcer policy as it pertains to prevention for outpatients.
No. 14
to Veterans Health Administration (VHA)
We recommended that the newly established Interprofessional Pressure Ulcer Committee meet as required and that the committee provide oversight of the facility’s pressure ulcer prevention program.
No. 15
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pressure ulcer data is analyzed and that program data is reported to facility executive leadership.
No. 16
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 17
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stage in initial skin assessments for patients at risk or with pressure ulcers and that compliance be monitored.
No. 18
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff develop interprofessional treatment plans for all hospitalized patients identified as being at risk for or with pressure ulcers and that compliance be monitored.
No. 19
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 20
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Date Issued
|
Report Number
13-02926-112
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended the Under Secretary for Health implement the corrective action plan included in the Performance and Accountability Report to reduce improper payments for the State Home Per Diem program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/15/2014
We recommended the Under Secretary for Health develop achievable reduction targets for the State Home Per Diem and Beneficiary Travel programs.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2014
We recommended the Under Secretary for Benefits ensure thorough procedures for testing sample items used to estimate improper payments for the Compensation and Post 9/11 G.I. Bill programs.
Date Issued
|
Report Number
13-02649-120
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/22/2014
We recommend that the Deputy Under Secretary for Health Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/22/2014
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the Director.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommend that the DUSHOM confer with OGC and OHRI to determine and execute a plan to provide all VHA employees involved in the RA process, as well as Regional Counsels who provide them advice, the most up to date RA training and guidance, and direct all VHA employees to process RA requests in accordance with applicable Federal laws and regulations and VA policy.
Date Issued
|
Report Number
14-00305-123
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that the Surgical Work Group meet monthly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that patient care areas in the CLC are clean and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that walls in the CLC are repaired and maintained.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that all workers who occasionally access the acute MH receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA’s National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that clinicians identify post-discharge needs and include them in discharge planning.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services within the ordered/expected timeframe.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in May 2013.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff revise the prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale and how to conduct a complete skin assessment and that compliance be monitored.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that staff document weekly summaries of restorative nursing services in residents’ EHRs.
Date Issued
|
Report Number
14-00234-125
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that fire drills are performed every 12 months at the Reading CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that CBOC and PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that CBOC and PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/24/2014
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.
Date Issued
|
Report Number
14-00658-121
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/23/2014
We recommended that the Blood Usage Review Sub-Committee include a clinical representative from Medicine Service as a member.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes consistently reflect EOC findings from community based outpatient clinic inspections.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that processes be strengthened to ensure patient care areas are clean and that water leaks and subsequent structural damage are addressed and resolved timely and that compliance be monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that processes be strengthened to ensure that expired medical supplies and medications are removed from patient care areas and that compliance be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/10/2014
We recommended that all emergency exits on the locked MH unit be alarmed.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the EHRs and that they validate patients' and/or caregivers' understanding of the discharge instructions they provided and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/23/2014
We recommended that the annual staffing plan reassessment process ensures that unit 2NE's and unit 4SW's unit-based expert panels include all required members and that all members of the unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that nurse managers reassess the target nursing hours per patient day for unit 2NE to more accurately plan for staffing and evaluate the actual staffing provided.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/9/2015
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings, and that compliance be monitored.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
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.