All Reports

Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey
|
13-00886-210

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that the local observation bed policy be revised to include all required elements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2014
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: 1/2/2014
We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes and that code sheets are scanned into the EHRs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2014
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that sensitive patient information is secured on computer screens in the ED.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that medical equipment in the ED is terminally cleaned after patient discharge.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that processes be strengthened to ensure that supplies and equipment in the East Orange PT clinic are properly stored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that facility policy be amended to address that the CS Coordinator PD or functional statement must include CS inspection and coordination, to include that the CS Coordinator must have complete understanding of CS policies and VHA inspection process, and to include requirements for new CS inspector orientation and annual training thereafter.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2014
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2014
We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2014
We recommended that processes be strengthened to ensure that home oxygen program patients deemed to be high risk have fire risk assessments completed and that 3-month follow-up evaluations are completed for all home oxygen program patients.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that unit 9A's expert panel include all required members.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that managers initiate protected peer review for the identified patient and complete any recommended review actions.
Community Based Outpatient Clinic Reviews at Central Texas Veterans Health Care System, Temple, TX, and VA Texas Valley Coastal Bend Health Care System, Harlingen, TX
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13-00026-213

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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 results within the defined timeframe and that notification is documented in the EHR.
No. 2
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 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)
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)
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Cedar Park CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Corpus Christi Satellite, Harlingen OPC, and Laredo CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the Corpus Christi Satellite, Harlingen OPC, and McAllen Satellite to clearly identify the location of fire extinguishers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a panic alarm system is installed at the Laredo CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispen
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the placement of the telecommunications network beevaluated and that appropriate safety measures are implemented at theCorpus Christi Satellite.
Combined Assessment Program Review of the Spokane VA Medical Center, Spokane, Washington
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13-00432-217

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
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: 12/16/2013
We recommended that processes be strengthened to ensure that the CACC reviews each code episode.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2014
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person and a dedicated psychologist or other mental health provider.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2014
We recommended that the PCCT provide end-of-life training on a regular basis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2014
We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that HPC consults are acted upon within 7 days of the request.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed within 4 hours following an intervention and results documented in the EHR and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that pain interventions identified on HPC inpatients' IPCs are consistently implemented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that IPCs specify responsible team members.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that the CLC social worker documents in the EHR that the CLC condolence letter was sent.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that the facility establish an HRCT.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that the facility conduct periodic, unscheduled onsite visits to the oxygen delivery contractor.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that home oxygen program patients have active prescriptions and that patients are re-evaluated for home oxygen therapy annually after the first year.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2014
We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2014
We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2014
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. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in August 2011.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that processes be strengthened to ensure that documentation of construction site inspections includes all required elements.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in ICC minutes.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that processes be strengthened to ensure that CSC minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that processes be strengthened to ensure that when required, continuous negative air pressure is achieved prior to initiating work at a construction site.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that processes be strengthened to ensure that physician orders and discharge summaries are consistent.
Combined Assessment Program Summary Report - Evaluation of Colorectal Cancer Screening and Follow-Up in Veterans Health Administration Facilities
|
13-01741-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2015
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Inspection of VA Regional Office Wilmington, Deleware
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12-04328-211

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/13/2013
We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and timely schedule medical reexaminations when the reminder notifications generate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2013
We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits when appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/13/2013
We recommend the Wilmington VA Regional Office Director conduct a review of the 57 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/13/2013
We recommend the Wilmington 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 under the VA Regional Office's jurisdiction.
Community Based Outpatient Clinic Reviews at Oklahoma City VA Medical Center, Oklahoma City, OK
|
13-00026-212

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that processes are strengthened to ensure that the ordering provider or surrogate is notified of normal 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: 11/12/2013
We recommended that processes are strengthened to ensure that patients with normal 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: 11/12/2013
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: 11/12/2013
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the PSB grants setting-specific clinical privileges for all providers at the Ardmore and Enid CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that handicapped parking spaces at the Enid CBOC meet ADA requirements for parking space identification.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that restroom access is improved for disabled veterans at the Ardmore and Enid CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that laboratory specimens are secured during transport from the Ardmore and Enid CBOCs to the parent facility.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the IT server closets are maintained according to IT safety and security standards at the Ardmore and Enid CBOCs.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that managers ensure that an AED is available at the Enid CBOC.
Community Based Outpatient Clinic Reviews at North Florida/South Georgia Veterans Health System, Gainesville, FL
|
13-00026-207

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that the MEC grants privileges consistent with the services provided at the Ocala CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that fire drills are performed every 12 months at the Ocala CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that patient privacy is maintained in the examination rooms at the Ocala and St. Marys CBOCs.
Combined Assessment Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
|
13-00376-201

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that the results of FPPEs for newly hired LIPs are consistently reported to the ECOMS.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
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: 11/22/2013
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2014
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2014
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that patient care equipment is consistently cleaned between patient use.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that gloves in all sizes and gowns are available in the therapy clinic areas.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that inspectors are sufficiently rotated in inspection assignments and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that inspectors do not participate in inspections beyond their 3-year appointment expiration date and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated nurse, social worker, and administrative support person and a 0.25 FTE psychologist or other MH provider.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2014
We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that unit 134-3Cs nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2013
We recommended that managers initiate protected PR for the identified patient and complete any recommended review actions.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that processes be strengthened to ensure that routine construction site inspections are conducted by the required CSC members, include all required elements, and are documented.
Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia
|
13-00889-206

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each CPR episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that the facility continue to monitor the EHR copy and paste function.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that the blood usage and review process includes the number of transfusions and number reviewed for appropriateness, the results of proficiency testing, PRs when transfusions did not meet criteria, and results of inspections by government or private (peer) entities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that when data analyses indicate problems or opportunities for improvement, actions taken are consistently followed to resolution in utilization management, outcomes of resuscitation, and RAI/MDS quality reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that processes be strengthened to ensure that Infection Control Committee actions are implemented to address high-risk areas and that committee minutes document those actions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that processes be strengthened to ensure that Infection Control Committee minutes consistently reflect analysis of surveillance activities.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that floors, ventilation system outlets, and horizontal surfaces in patient care areas are clean and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that mattresses, pillows, geri-chairs, and treatment table mats are routinely inspected and that those with compromised surfaces are repaired or removed from service.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that processes be strengthened to ensure that expired commercial supplies are removed from patient care areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that women's health clinic exit signage is properly oriented and visible from all hallways.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education be documented.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that the Home Respiratory Care Committee evaluates patient safety-related events for home oxygen patients and planning for patients discontinued from home oxygen therapy to determine whether additional actions are warranted.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that all members of unit 4H/4J's expert panel receive the required training prior to the next annual staffing plan reassessment.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers complete protected PR for the identified patient and any recommended review actions.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that the Construction Safety Committee oversees construction and renovation activities, that the policy outlining the responsibilities of the committee is followed, that the multidisciplinary team conducts site visits at the specified frequency, and that meeting minutes contain discussion of site conditions and any required follow-up.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that designated employees receive initial and/or refresher construction safety training and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that ED staff document discharge instructions and evaluate patient and/or caregiver understanding of the discharge instructions.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2014
We recommended that processes be strengthened to ensure that the process for requesting and granting ED staff privileges complies with VHA policy.
Combined Assessment Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia
|
13-00378-202

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the local observation bed policy be revised to include all required elements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the all fire extinguishers have signage in accordance with National Fire Protection Association standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that construction workers remove cardboard boxes in the outpatient pharmacy promptly or store them off the floor.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the facility implement the mandated staffing methodology for nursing personnel.
Combined Assessment Program Review of the VA Southern Nevada Healthcare System, Las Vegas, Nevada
|
13-00888-203

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that processes be strengthened to ensure that actions from PRs are consistently completed and reported to the PR Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2014
We recommended that the facility monitor compliance with the recently implemented observation bed use policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2014
We recommended that managers initiate actions to address identified deficiencies in the PCC pharmacies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that the facility develop instructions for inspecting automated dispensing machines that include all VHA requirements and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that processes be strengthened to ensure that the CS Coordinator only performs occasional inspections and that a sufficient number of CS inspectors are appointed to conduct the monthly inspections.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2014
We recommended that the facility fully implement the nurse staffing methodology.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that managers initiate protected PR for the one identified patient and complete any recommended review actions.
Combined Assessment Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky
|
13-00433-199

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
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: 11/26/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that the quality control process for scanning includes methods to ensure that scanned documents are linked to the correct EHR.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that the WVPM completes the required annual EOC evaluation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that identified women's health-related EOC deficiencies are tracked to closure.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2014
We recommended that processes be strengthened to ensure that examination and treatment rooms designated for female patients have door locks.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that an After Installation Checklist be completed for the ceiling lift in the physical therapy clinic.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated in a timely manner.
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois
|
13-00887-204

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
We recommended that the local observation bed policy be revised to include all required elements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the codes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2013
We recommended that the local blood usage policy be revised to define criteria for appropriateness of transfusions and that processes be strengthened to ensure that the blood usage review process includes consistent reporting of transfusion appropriateness; the number of units outdated or discarded; and results of proficiency testing, peer reviews, and inspections.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2013
We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the CPRS.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2013
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Community Based Outpatient Clinic Reviews at Sioux Falls VA Health Care System, Sioux Falls, SD
|
13-00026-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that the Antelope Valley CBOC IT closet is maintained according to IT security standards
Community Based Outpatient Clinic Reviews at VA Maine Healthcare System, Augusta, ME
|
13-00026-197

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2013
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 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: 1/6/2014
We recommended that managers ensure that patients with normal 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: 11/8/2013
We recommended that patients' PII is protected and secured at the Bangor CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2014
We recommended that the Chief of OI&T evaluates security of the IT closet and implements required measures at the Bangor CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2013
We recommended that all identified EOC deficiencies and corrective actions at the Bangor and Calais CBOCs are tracked and trended by the EOC Committee.
Community Based Outpatient Clinic Reviews at Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
|
13-00026-196

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2013
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal 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: 9/18/2013
We recommended that managers ensure that patients with normal 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: 9/18/2013
We recommended that the Acting Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2013
We recommended that laboratory specimens are secured during transport from the CBOCs to the parent facility to prevent the disclosure of patients' PII.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2013
We recommended that all identified EOC deficiencies and corrective actions be tracked and trended by the EOC Committee.
Healthcare Inspection – Alleged Delays in Notifying Patients of Biopsy Results, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC
|
13-00940-193

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that the Facility Director implement procedures to ensure that patient notifications are timely and documented in patients' electronic health records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that the Facility Director ensure that performance improvement processes be strengthened to include periodic monitoring of test result communication to patients.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the Facility Director ensure that the facility's written policy on critical test results addresses critical biopsy test results from outpatient procedures.
Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York
|
13-01320-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that the Under Secretary for Health finalize VHA's Clinical Operations Guideline for 'Implementation of a Large Scale Disclosure Decision' to include a monitoring process that reflects the urgency of disclosing adverse events to patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2013
We recommended that the VISN Director review the facts that led to the misuse of insulin pens and take appropriate administrative action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2013
We recommended that the Facility Director implement a process to ensure the facility's Medication Use, Nursing Practice, and Commodity Standards Committees and other relevant leadership evaluate the risks and benefits before introducing new medical products or supplies that require changes in nursing procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2013
We recommended that the Facility Director strengthen nurse education practices when introducing new medical products or supplies and ensure that all nurses are made aware of how to find and use the facility's nursing practice procedures.
Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas
|
13-00893-195

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates or refresher training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2013
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Community Based Outpatient Clinic Reviews at Cheyenne VA Medical Center, Cheyenne, WY
|
13-00026-191

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommend that the CBOC IT server closet is maintained according to IT safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that all identified EOC deficiencies are tracked, trended, and corrected.
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