Recommendations
1206
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00378-202 | Combined Assessment Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that the all fire extinguishers have signage in accordance with National Fire Protection Association standards.
Closure Date:
4 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.
Closure Date:
5 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
6 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:
7 We recommended that the facility implement the mandated staffing methodology for nursing personnel.
Closure Date:
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| 13-00433-199 | Combined Assessment Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky | Comprehensive Healthcare Inspection Program | ||
| 13-00887-204 | Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
2 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.
Closure Date:
3 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
4 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that the blood usage review process includes consistent reporting of transfusion appropriateness; the number of units outdated or discarded; and results of proficiency testing, peer reviews, and inspections.
Closure Date:
5 We recommended that processes be strengthened to ensure that
HPC consult responses are attached to the consult request in the CPRS.
Closure Date:
6 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
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| 13-00026-198 | Community Based Outpatient Clinic Reviews at Sioux Falls VA Health Care System, Sioux Falls, SD | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
2 We recommended that the Antelope Valley CBOC IT closet is maintained according to IT security standards
Closure Date:
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| 13-00026-197 | Community Based Outpatient Clinic Reviews at VA Maine Healthcare System, Augusta, ME | Comprehensive Healthcare Inspection Program | ||
1 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.
Closure Date:
2 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.
Closure Date:
3 We recommended that patients' PII is protected and secured at the Bangor CBOC.
Closure Date:
4 We recommended that the Chief of OI&T evaluates security of the IT closet and implements required measures at the Bangor CBOC.
Closure Date:
5 We recommended that all identified EOC deficiencies and corrective actions at the Bangor and Calais CBOCs are tracked and trended by the EOC Committee.
Closure Date:
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| 13-00026-196 | Community Based Outpatient Clinic Reviews at Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA | Comprehensive Healthcare Inspection Program | ||
1 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.
Closure Date:
2 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.
Closure Date:
3 We recommended that the Acting Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
Closure Date:
4 We recommended that laboratory specimens are secured during transport from the CBOCs to the parent facility to prevent the disclosure of patients' PII.
Closure Date:
5 We recommended that all identified EOC deficiencies and corrective actions be tracked and trended by the EOC Committee.
Closure Date:
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| 13-00940-193 | Healthcare Inspection – Alleged Delays in Notifying Patients of Biopsy Results, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC | Hotline Healthcare Inspection | ||
| 13-01320-200 | Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York | Hotline Healthcare Inspection | ||
1 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.
Closure Date:
2 We recommended that the VISN Director review the facts that led to the misuse of insulin pens and take appropriate administrative action.
Closure Date:
3 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.
Closure Date:
4 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.
Closure Date:
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| 13-00893-195 | Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 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.
Closure Date:
2 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates or refresher training.
Closure Date:
3 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
Closure Date:
4 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.
Closure Date:
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| 13-00026-191 | Community Based Outpatient Clinic Reviews at Cheyenne VA Medical Center, Cheyenne, WY | Comprehensive Healthcare Inspection Program | ||
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