Recommendations
1229
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01669-270 | Combined Assessment Program Review of the Jesse Brown VA Medical Center, Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include how the service and physician responsible for the patient are determined.
Closure Date:
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
3 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing, of PRs when transfusions do not meet criteria, and of inspections by government or private (peer) entities.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
5 We recommended that processes be strengthened to ensure that Infection Prevention and Control Committee minutes reflect discussion of high-risk areas and actions implemented to address these areas.
Closure Date:
6 We recommended that processes be strengthened to ensure that all Infection Prevention and Control Committee members or their designees participate in meetings and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that Infection Prevention and Control Committee minutes reflect discussion of hand hygiene compliance, follow-up actions, and action results.
Closure Date:
8 We recommended that processes be strengthened to ensure that monthly hemodialysis dialysate testing includes endotoxins.
Closure Date:
9 We recommended that processes be strengthened to ensure that SPS employees receive annual competency assessments for all RME items they reprocess.
Closure Date:
10 We recommended that processes be strengthened to ensure that SPS temperature and humidity level monitoring is consistently documented and that compliance be monitored.
Closure Date:
11 We recommended that managers initiate actions to address the identified deficiency and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
12 We recommended that the facility pressure ulcer policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that Infection Prevention and Control Committee minutes include pressure ulcer data analysis.
Closure Date:
14 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
15 We recommended that nursing managers monitor the staffing methodology that was implemented in February 2013.
Closure Date:
16 We recommended that the CSC continues to meet and ensures appropriate oversight of construction and renovation activities.
Closure Date:
17 We recommended that processes be strengthened to ensure that all CSC members or their designees consistently attend required meetings and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that a contractor tuberculosis risk assessment is conducted prior to construction project initiation.
Closure Date:
19 We recommended that processes be strengthened to ensure that construction site inspections are conducted at the facility's required frequency and documented.
Closure Date:
20 We recommended that processes be strengthened to ensure that designated employees receive initial and ongoing construction safety training and that compliance be monitored.
Closure Date:
21 We recommended that processes be strengthened to ensure that contractor safety training is verified prior to project initiation.
Closure Date:
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| 12-00040-268 | Vet Center Contracted Care Program Review | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders receive, review, and approve psychosocial assessments and counseling plans prior to authorizing contracted counseling services.
2 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct and document client assessments after 1 year of eligibility for contracted client services.
3 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct annual onsite quality reviews for contractors who participate in the Contract for Fee Program.
4 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service uses a standard template that includes terms and conditions that are consistent with those in the Readjustment Counseling Service policy.
5 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service maintains and monitors counseling service contracts in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
6 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders authorize contracted counseling services in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
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| 13-00026-279 | Community Based Outpatient Clinic Reviews at VA Pittsburgh Healthcare System, Pittsburgh, PA | Comprehensive Healthcare Inspection Program | ||
1 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.
Closure Date:
2 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
3 We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
4 We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Fayette County and Washington County CBOCs.
Closure Date:
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| 13-00026-281 | Community Based Outpatient Clinic Reviews at Louis A. Johnson VA Medical Center, Clarksburg, WV | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommended that biohazardous waste containers are available in the CBOC.
Closure Date:
3 We recommended that managers maintain a written, current inventory of hazardous materials at the CBOC.
Closure Date:
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| 13-02235-277 | Healthcare Inspection - Alleged Patient Rights, Quality of Care, and Other Issues, VA Puget Sound Health Care System, Seattle, Washington | Hotline Healthcare Inspection | ||
1 We recommended the System Director ensure the Women Veterans Program Manager provides chaperone policy education to all system primary care clinics and monitors compliance.
Closure Date:
2 We recommended the System Director ensure all staff are informed about the VHA requirement to report allegations of patient abuse and educated on the processes for reporting the alleged abuse.
Closure Date:
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| 13-01671-262 | Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that ECC membership includes all required disciplines.
Closure Date:
2 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of non-VA purchased care are consistently scanned into EHRs.
Closure Date:
4 We recommended that processes be strengthened to ensure that results of compliance with RME SOPs are reported to the RME Management Committee and the MEB.
Closure Date:
5 We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive initial RME training and annual competency assessments.
Closure Date:
6 We recommended that processes be strengthened to ensure that manufacturers’ instructions are available for all RME items, that RME is reprocessed at the specified temperature, and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that SPS sterile storage area temperature and humidity levels are consistently monitored and maintained within acceptable levels.
Closure Date:
8 We recommended that facility policy be amended to include the requirement that CS inspectors receive annual updates regarding problematic issues identified through external survey findings and other quality control measures and that processes be strengthened to ensure that CS inspectors receive annual updates.
Closure Date:
9 We recommended that the facility develop instructions for inspections of automated dispensing machines and that processes be strengthened to ensure that monthly findings summaries are provided to the facility Director and that quarterly trend reports clearly summarize discrepancies and problematic trends and identify potential areas for improvement.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors’ appointments state the end date of their term and that CS inspectors’ terms do not exceed 3 years.
Closure Date:
11 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS are conducted in accordance with VHA requirements and include all required elements and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
13 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.
Closure Date:
14 We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
Closure Date:
15 We recommended that processes be strengthened to ensure that HPC inpatients’ pain is consistently assessed whenever vital signs are obtained and results documented in EHRs and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that HPC inpatients’ pain assessments are documented in EHRs using approved note titles and that compliance be monitored.
Closure Date:
17 We recommended that the interprofessional pressure ulcer committee includes a certified wound care specialist.
Closure Date:
18 We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer location and stage and perform and document all required daily activities/inspections for patients with pressure ulcers and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
Closure Date:
20 We recommended that processes be strengthened to ensure that acute care staff perform and document skin inspections and risk scales at discharge and that compliance be monitored.
Closure Date:
21 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to discharge and that compliance be monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients and/or their caregivers and that compliance be monitored.
Closure Date:
23 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
24 We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.
Closure Date:
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| 12-01860-237 | Audit of Non-Purchase Card Micro-Purchases | Audit | ||
1 We recommended the Under Secretary for Health collaborate with the VA Office of Management to establish policies and procedures to regularly identify and evaluate the universe of micro-purchases and non-purchase card micro-purchases to monitor the level of Veterans Health Administration use of purchase cards.
Closure Date:
2 We recommended the Under Secretary for Health establish annual and long-term strategic goals to increase the percentage of VA medical facility micro-purchases made with purchase cards.
Closure Date:
3 We recommended the Under Secretary for Health implement mechanisms to ensure purchasers and approvers adequately consider purchase card use for micro-purchases.
Closure Date:
4 We recommended the Under Secretary for Health modify policies and procedures requiring Veterans Integrated Service Networks to perform oversight of non-purchase card micro-purchases that identifies opportunities for increased use of purchase cards.
Closure Date:
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| 13-01445-271 | Inspection of VA Regional Office Milwaukee, Wisconsin | Review | ||
| 13-01670-269 | Combined Assessment Program Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that VA Police conduct annual physical security surveys of the pharmacy areas and that any identified deficiencies be corrected.
Closure Date:
2 We recommended that processes be strengthened to ensure that the PCCT includes an administrative support person and a dedicated psychologist or other MH professional.
Closure Date:
3 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.
Closure Date:
4 We recommended that the facility pressure ulcer policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer was acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology that was implemented in December 2012.
Closure Date:
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| 13-01675-266 | Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the PCCT includes a 0.25 full-time employee equivalent psychologist or other mental health provider.
Closure Date:
2 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon discharge and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, assessments for change in condition, and/or revisions to prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
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11259