All Reports

Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities
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13-01189-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2014
We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Healthcare Inspection - Follow-Up Assessment of Radiation Therapy, VA Long Beach Healthcare System, Long Beach, California
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13-00696-254

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2013
We recommended that the Under Secretary for Health ensure that repeated deficiencies in the documentation of patient care are addressed and do not persist.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that the VISN Director ensure that complications of radiation therapy that are managed at referring facilities are reported to the facility where radiation therapy was provided.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2014
We recommended that the VISN Director require that the facility Director ensure that radiation therapists adhere to local policy when shifts in the field of delivered radiation occur.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that the VISN Director require that the facility Director ensure that adverse events in the Radiation Oncology department are consistently reported to facility managers as specified in the facility’s action plan in response to the 2011 OIG report.
Inspection of VA Regional Office Waco, Texas
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13-00368-244

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2014
We recommend the Waco VA Regional Office Director conduct a review of the 795 temporary 100 percent disability evaluations remaining from the data we used to perform the inspection and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2014
We recommend the Waco VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of the training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommend the Waco VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration policy requiring second-signature review of each traumatic brain injury claim processed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommend that the Waco VA Regional Office Director develop and implement a plan to ensure staff follow Veterans Benefits Administration policy in including recommendations for identified problems in their Systematic Analyses of Operations.
Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas
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13-01988-253

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2013
We recommended that the System Director consult with Regional Counsel to determine if a disclosure of the events related to the patient's episode of acute renal failure, as discussed in this report, is indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2014
We recommended that the System Director ensure that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.
Inspection of VA Regional Office Jackson, Mississippi
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13-00709-257

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and schedule medical reexaminations as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to review the 195 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration and local second-signature requirements for traumatic brain injury claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2013
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers within the VA Regional Office's jurisdiction.
Community Based Outpatient Clinic Reviews at Hunter Holmes McGuire VA Medical Center, Richmond, VA
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13-00026-258

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2013
We recommended that the PSB submits actions and recommendations for privileging and reprivileging to the MPSC and that meeting minutes reflect documents reviewed and the rationale for privileging or reprivileging at the Charlottesville and Emporia CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers minimize risks associated with the handling, storing, and disposing of hazardous materials in the hazardous waste storage room at the Charlottesville CBOC.
Combined Assessment Program Review of the Sioux Falls VA Health Care System, Sioux Falls, South Dakota
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13-01674-256

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scale scores upon change in condition and/or at discharge and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff revise interprofessional treatment plans when there are risk level changes and that compliance be monitored.
Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania
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13-01672-260

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that a process be established to track HPC consults that are not acted upon within 4 days of the request.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that processes be strengthened to ensure that HPC inpatients pain is consistently reassessed and that results are documented timely in EHRs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that monthly DCHV Program and SA domiciliary self-inspection documentation includes all required elements.
Community Based Outpatient Clinic Review at Jack C. Montgomery VA Medical Center, Muskogee, OK
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13-00026-259

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Community Based Outpatient Clinic Reviews at Amarillo VA Health Care System, Amarillo, TX and Northern Arizona VA Health Care System, Prescott, AZ
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13-00026-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that a process be established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians administer tetanus vaccines when indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that the PSB grants privileges consistent with the services provided at the Lubbock CBOC.
Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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13-01123-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director ensure that the patient (case 1) endof-life care undergoes a quality review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director ensure that CLC staff are appropriately trained and competent to care for all CLC residents, regardless of the residents' special care needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director conduct a risk assessment of the electronic monitoring system and implement improvements, as indicated.
Community Based Outpatient Clinic Reviews at Edward Hines, Jr. VA Hospital, Hines, IL
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13-00026-251

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that managers ensure that patients with normal and abnormal cervical cancer screening results are notified within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that managers ensure that all specified medical equipment receive PM according to local policy at the Kankakee CBOC.
Community Based Outpatient Clinic Reviews at VA Butler Healthcare, Butler, PA
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13-00026-248

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that signage is installed to direct physically challenged patients to the handicapped accessible entrance of the Armstrong County CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure all exit routes be clearly identified at the Armstrong County CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Armstrong County CBOC to the contracted processing facility.
Combined Assessment Program Review of the James A. Haley Veterans’ Hospital, Tampa, Florida
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13-01971-245

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2014
We recommended that processes be strengthened to ensure that all services are included in the review of EHR quality.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the MH units, corrective actions taken, and tracking of corrective actions to closure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that sterile storage rooms are secured at all times and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2014
We recommended that processes be strengthened to ensure that staff competency validation results and results of compliance with RME SOPs are reported to the Clinical Executive Board.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities have initial training and annual competency validation documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization have initial training and annual competency validation documented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that the SPS eyewash station is checked weekly and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that the SPS decontamination area is clean.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that monthly CS findings summaries and quarterly trend reports are provided to the facility Director consistently and timely.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that IC and tuberculosis risk assessments are conducted prior to construction project initiation.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York
|
13-00897-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are initiated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that the local observation bed policy be revised to include all required elements and that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that the blood usage and review process includes the number of units that were outdated or otherwise discarded, the results of proficiency testing, and the results of inspections by government or private (peer) entities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled; that hard copy orders for 5 randomly selected dispensing activities are validated in all non-pharmacy CS areas; and that at the Batavia pharmacy, audit trails for destruction of 10 randomly selected drugs are consistently verified.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that staff are consistent in pressure ulcer documentation of location, stage, size, characteristics, risk scale score, and date acquired and whether the wound has improved or deteriorated during the admission or at the time of discharge.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that staff consistently perform and document daily skin inspections and/or daily risk scales.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that pressure ulcer education is provided to patients at risk for or with pressure ulcers and/or their caregivers.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that designated employees receive training on how to accurately document pressure ulcer findings and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that nurse managers monitor the staffing methodology that was implemented in December 2012.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Community Based Outpatient Clinic Reviews at Jesse Brown VA Medical Center, Chicago, IL
|
13-00026-233

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of abnormal cervical cancer screening results within the allotted timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2014
We recommended that managers ensure that patients with abnormal cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2014
We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging providers at the Chicago Heights and Lakeside CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that the MEC grants privileges consistent with the services provided at the Chicago Heights and Lakeside CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2014
We recommended that managers ensure that MSDS are readily available to staff at the Lakeside CBOC.
Inspection of VA Regional Office San Juan, Puerto Rico
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13-00586-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries to the electronic record as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to review for accuracy the 132 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure effective second-signature reviews of traumatic brain injury claims decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure staff completely and timely address all required elements of Systematic Analyses of Operations.
Combined Assessment Program Review of the VA Maryland Health Care System, Baltimore, Maryland
|
13-00896-234

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2014
We recommended that the local observation bed policy be revised to include all required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the events.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that the quality control policy for scanning includes linking the scanned documents to the correct record.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that oxygen tanks are properly secured and stored in a manner that distinguishes between empty and full tanks.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2014
We recommended that processes be strengthened to ensure that soiled utility rooms are secured at all times.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that EOC rounds are consistently conducted in the Annex building in accordance with VHA and local policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that facility policy be amended to include that CS Coordinators must have complete understanding of CS policies and the VHA inspection process and to include requirements for new CS inspector orientation and/or annual training thereafter.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2014
We recommended that the instructions for inspecting automated dispensing machines be amended to include monthly CS inspector reconciliation of 1 day's dispensing activity and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that processes be strengthened to ensure that acute care staff consistently provide and document completion of recommended PU interventions and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that the facility establish staff PU education requirements and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that nursing managers ensure compliance with all elements of the staffing methodology that was implemented in December 2012.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that the facility ensure that the multidisciplinary committee responsible for construction and renovation oversight includes all required members.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted prior to construction project initiation.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
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