All Reports

Healthcare Inspection – Questionable Cardiac Interventions and Poor Management of Cardiovascular Care, Edward Hines, Jr. VA Hospital, Hines, Illinois
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13-02053-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that cardiologists performing coronary interventions and surgeons performing cardiac surgery adhere to accepted standards of care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that adequate equipment is available in the operating room in accordance with VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that processes are strengthened to improve bed utilization.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that processes are strengthened to ensure contract oversight in accordance with VA requirements.
Combined Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico
|
14-00659-111

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that the PRC’s membership be revised to ensure that sufficient experienced senior physicians are regular members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently reported to the PRC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that the Surgical Work Group meet monthly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that all critical incidents are reported through the patient incident reporting process.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that the Blood Utilization Review Committee members from Surgery and Anesthesia Services consistently attend meetings and that the blood usage review process includes the results of proficiency testing.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that the local observation bed policy be revised to include all required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that EOC and Administrative Executive Board Committee minutes reflect deficiencies identified on the locked MH unit.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2014
We recommended that processes be strengthened to ensure that cabinets containing contrast agents in the radiology area are secured at all times and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that crash cart checks in the radiology area are documented daily and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that all MH unit staff and occasional 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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that panic alarm testing documentation includes police response times and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2014
We recommended that processes be strengthened to ensure that the medication list provided to the patient/caregiver at discharge is reconciled with the dosage and frequency ordered and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2014
We recommended that processes be strengthened to ensure that patients are provided with correct information on discharge instructions.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that patients’ post-hospitalization outpatient appointments are scheduled within the timeframe requested by the discharging physician.
Healthcare Inspection – Administrative Irregularities, Leadership Lapses, and Quality of Care Concerns, VA Central Iowa Health Care System, Des Moines, Iowa
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13-02073-106

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated System Network Director ensure that the Chief of Staff appoints a director of the specific unit of the subject Service Line, who meets the qualification standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that selection of physicians who will be participating in medical educational activities is conducted within the standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure the implementation of a standardized process for the management of cardiology consults, consistent with VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure processes be strengthened so that Focused Professional Practice Evaluations for licensed independent practitioners are consistently conducted as required, and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the Chief of Staff maintain a comprehensive list of staff that is authorized to perform out of Operating Room airway management in compliance with facility policy.
Combined Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana
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14-00308-105

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that the Blood Utilization Review Committee include a clinical representative from Surgery Service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that corrective actions are initiated and/or consistently followed to resolution when data analyses indicated problems or opportunities for improvement in the Performance Improvement, Medical Executive, and Executive Safety Committees.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that processes be strengthened to ensure that patient care areas and restrooms are clean and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that processes be strengthened to ensure that holes in the walls are repaired and that ongoing maintenance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff 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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that the annual staffing plan reassessment process ensures that unit 6E's and unit 9E's unit-based expert panels include all required members.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that Interprofessional Skin Integrity Committee minutes include data analysis.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
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.
Audit of VHA's Supportive Services for Veteran Families Program
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13-01959-109

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2014
We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program implement a mechanism to inform grantees when updated area median income limits are published.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2014
We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program grantees follow up to obtain the required Certificate of Release or Discharge from Active Duty (DD 214) when interim documents are used to determine program eligibility.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Loma Linda Healthcare System, Loma Linda, California
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14-00232-110

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Rancho Cucamonga CBOC to the VA Loma Linda Healthcare System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommend that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that CBOC/PCC RN Care Managers receive motivational interviewing training within 12 months of appointment to PACT.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Healthcare Inspection – Unexpected Patient Death in a Substance Abuse Residential Rehabilitation Treatment Program, Miami VA Healthcare System, Miami, Florida
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13-03089-104

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that the camera surveillance system is repaired and maintained and that surveillance is conducted as required on the SARRTP unit.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that the SARRTP unit is appropriately staffed at all times, as required by VHA and local policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that SARRTP staff implement a consistent and comprehensive approach to check patients returning to the unit for contraband and document results clearly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that SARRTP staff more aggressively monitor patients for illicit drug use, to include increasing the use of random UDS and adhering to local and VHA policy when patients leave the unit.
Combined Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York
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13-03620-102

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2014
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2014
We recommended that the Surgical Work Group meet monthly, include the Chief of Staff and VASQIP nurse as members, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2014
We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on the 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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2014
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scales daily, upon transfer, and at discharge and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stages and revise treatment plans when risk levels change and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that 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.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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13-03422-99

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
No. 4
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Combined Assessment Program Review of the VA Eastern Colorado Health Care System,Denver, Colorado
|
14-00306-95

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2014
We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2014
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2014
We recommended that the Surgical Work Group meet monthly and include the Chief of Staff as a member.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2014
We recommended that the nurse staffing methodology be implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2014
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2014
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2014
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents¿ care plans and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2014
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2014
We recommended that processes be strengthened to ensure that there are no unnecessary disruptions during resident meal periods.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Eastern Colorado Health Care System, Denver, Colorado
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14-00223-93

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2014
We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2016
We recommended that all staff document that medication reconciliation was completed at each episode of care when the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Atlanta VA Medical Center, Decatur, Georgia
|
13-03419-90

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2014
We recommended that panic alarms are tested and testing is documented.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2014
We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Overton Brooks VA Medical Center, Shreveport, Louisiana
|
14-00228-94

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all identified environment of care deficiencies at the Monroe CBOC are reported to and tracked by the parent facility Executive Safety Committee until resolution.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility include staff at the Monroe CBOC in required education, training, planning, and participation in annual disaster exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Caribbean Health Care System, San Juan, Puerto Rico
|
14-00233-96

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that managers ensure that the hazardous materials inventory for the Arecibo CBOC is reviewed at least twice yearly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Arecibo CBOC to the parent facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2014
We recommended that managers ensure that women veterans can access gender-specific restrooms without entering public areas at the Arecibo CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
|
13-03549-92

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia
|
13-03653-91

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the PRC submit quarterly summary reports to the MEC and that the MEC document its discussion of the reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and collects code data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that the Surgical Work Group meet monthly and document its review of required performance data elements and National Surgical Office reports.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the quality control policy for scanning include how to annotate a scanned image to identify that it has been scanned.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that the Anesthesia Service representative attends Blood Usage Committee meetings and that the blood/transfusion usage review process includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2015
We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff, MSIT members, and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, the 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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response times.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the locked MH unit¿s seclusion room door open towards the hallway and that patients in seclusion have privacy while using the bathroom.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that all members of CLC-2's unit-based expert panel receive the required training prior to the next annual staffing plan reassessment.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the newly established interprofessional pressure ulcer committee continue to meet and that the committee provide oversight of the facility's pressure ulcer prevention program.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education to patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that all employees who perform restorative nursing services receive training on and competency assessment for ROM and resident transfers.
Combined Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
|
13-03623-89

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2014
We recommended that processes be strengthened to ensure that the ICU Committee reviews each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the MRC analyze all reports of EHR quality review results
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that processes be strengthened to ensure that a member from Surgery Service attends Ancillary Testing Committee meetings, that a clinical representative from Anesthesia Service is added as an Ancillary Testing Committee member, and that the blood/transfusions usage review process includes the results of peer reviews when transfusions did not meet criteria.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that processes be strengthened to ensure that staff provide timely restorative nursing services to residents who are candidates for those services and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify interventions as needed, and document the modifications and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Salt Lake City Health Care System, Salt Lake City, Utah
|
13-03420-85

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that the main entrance door access is ADA accessible at the Roosevelt CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that gowned women veterans have access to gender-specific restrooms without entering public areas at the Roosevelt CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that CBOC/PCC staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
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