Recommendations
1061
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03744-84 | Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Staff Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
Closure Date:
3 We recommended that processes be strengthened to ensure that conversions from observation bed status to acute admissions are consistently 30 percent or less.
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4 We recommended that processes be strengthened to ensure that patient care areas are clean and well maintained and clean and dirty supplies are stored separately and that compliance be monitored.
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5 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service and that the facility be well maintained.
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6 We recommended that processes be strengthened to ensure that damaged therapy mats in the Temple division physical therapy clinic are repaired or removed from service.
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7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
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8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated MH provider and an administrative support person.
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9 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
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10 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.
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11 We recommended that managers initiate a protected peer review for the three identified patients and complete any recommended review actions.
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12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
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| 12-03740-75 | Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
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2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
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3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
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4 We recommended that the quality control policy for scanning be revised to include image quality, linking of scanned documents to the correct record, and indexing the documents.
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5 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
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6 We recommended that processes be strengthened to ensure that required members from surgery and medicine attend Transfusion Committee meetings.
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7 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
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8 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
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9 We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results for all projects are documented.
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10 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of deficiencies and follow-up actions in response to unsafe conditions identified during inspections.
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11 We recommended that processes be strengthened to ensure that Material Safety Data Sheets for chemicals used in construction sites are located within the construction areas.
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| 12-02089-60 | Inspection of the VA Regional Office Anchorage, Alaska | Review | ||
1 We recommend the Anchorage VA Regional Office Director develop and implement a plan to monitor proposed disability evaluation reduction processing actions.
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2 We recommend the Anchorage VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims.
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3 We recommend the Anchorage VA Regional Office Director develop and implement a plan to assess the effectiveness of training for properly processing traumatic brain injury claims.
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4 We recommend the Anchorage VA Regional Office Director develop and implement controls to ensure management follows the Veterans Benefits Administration's policy and workload management plan for all claims pending for more than 1 year.
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5 We recommend the Anchorage VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations using thorough analysis.
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6 We recommend the Anchorage VA Regional Office Director develop and implement a plan to monitor the effectiveness of training to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War Veterans' entitlement to mental health treatment when denying service connection for mental disorders.
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| 11-01827-36 | Audit of VHA's Physician Staffing Levels for Specialty Care Services | Audit | ||
1 The Office of Inspector General recommends that the Under Secretary for Health approve a plan by the end of FY 2013 that ensures all specialty care services have productivity standards within 3 years.
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2 The Office of Inspector General recommends that the Under Secretary for Health establish productivity standards for at least five specialty care services by the end of FY 2013 and ensure medical facility personnel compare physician workload against these standards.
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3 The Office of Inspector General recommends that the Under Secretary for Health provide medical facility directors with more specific guidance on how to develop staffing plans and ensure medical facility management review them at least annually to ensure optimal efficiency.
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| 12-03543-73 | Healthcare Inspection – Alleged Patient Safety Deficiencies in the Community Living Center, Canandaigua VA Medical Center, Canandaigua, New York | Hotline Healthcare Inspection | ||
| 12-02352-72 | Healthcare Inspection – Pharmacy and Quality of Care Issues, VA Hudson Valley Health Care System, Castle Point, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Director ensure that the recommendations included in the Administrative Investigation Board report are complied with.
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2 We recommended that the Director ensure that all pharmacy staff be provided ethics training to ensure that employees report unethical behavior without fear of repercussion.
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| 12-03076-65 | Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
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2 We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
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3 We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
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4 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
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5 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
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6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
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7 We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.
Closure Date:
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| 10-01937-63 | Review of Allegations at VA Medical Center, Providence, Rhode Island | Audit | ||
| 12-03346-69 | Review of VHA's Minor Construction Program | Audit | ||
1 We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
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2 We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
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3 We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
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4 We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
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5 We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
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6 We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
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| 12-03741-61 | Combined Assessment Program Review of the VA Maine Healthcare System,Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
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2 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
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3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
Closure Date:
4 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
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5 We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
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6 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
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11259