Recommendations
1282
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01988-253 | Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the System Director consult with Regional Counsel to determine if a disclosure of the events related to the patient's episode of acute renal failure, as discussed in this report, is indicated.
Closure Date:
2 We recommended that the System Director ensure that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.
Closure Date:
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| 13-00026-258 | Community Based Outpatient Clinic Reviews at Hunter Holmes McGuire VA Medical Center, Richmond, VA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that the PSB submits actions and recommendations for privileging and reprivileging to the MPSC and that meeting minutes reflect documents reviewed and the rationale for privileging or reprivileging at the Charlottesville and Emporia CBOCs.
Closure Date:
4 We recommended that managers minimize risks associated with the handling, storing, and disposing of hazardous materials in the hazardous waste storage room at the Charlottesville CBOC.
Closure Date:
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| 13-01672-260 | Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
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 a process be established to track HPC consults that are not acted upon within 4 days of the request.
Closure Date:
4 We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
Closure Date:
5 We recommended that processes be strengthened to ensure that HPC inpatients pain is consistently reassessed and that results are documented timely in EHRs.
Closure Date:
6 We recommended that processes be strengthened to ensure that monthly DCHV Program and SA domiciliary self-inspection documentation includes all required elements.
Closure Date:
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| 13-01674-256 | Combined Assessment Program Review of the Sioux Falls VA Health Care System, Sioux Falls, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scale scores upon change in condition and/or at discharge and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that acute care staff revise interprofessional treatment plans when there are risk level changes and that compliance be monitored.
Closure Date:
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| 13-00026-259 | Community Based Outpatient Clinic Review at Jack C. Montgomery VA Medical Center, Muskogee, OK | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
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| 13-00026-252 | Community Based Outpatient Clinic Reviews at Amarillo VA Health Care System, Amarillo, TX and Northern Arizona VA Health Care System, Prescott, AZ | Comprehensive Healthcare Inspection Program | ||
| 13-01123-249 | Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director ensure that the patient (case 1) endof-life care undergoes a quality review.
Closure Date:
2 We recommended that the facility Director ensure that CLC staff are appropriately trained and competent to care for all CLC residents, regardless of the residents' special care needs.
Closure Date:
3 We recommended that the facility Director conduct a risk assessment of the electronic monitoring system and implement improvements, as indicated.
Closure Date:
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| 13-00026-251 | Community Based Outpatient Clinic Reviews at Edward Hines, Jr. VA Hospital, Hines, IL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that patients with normal and abnormal cervical cancer screening results are notified within the required timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that all specified medical equipment receive PM according to local policy at the Kankakee CBOC.
Closure Date:
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| 13-00026-248 | Community Based Outpatient Clinic Reviews at VA Butler Healthcare, Butler, PA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that signage is installed to direct physically challenged patients to the handicapped accessible entrance of the Armstrong County CBOC.
Closure Date:
5 We recommended that managers ensure all exit routes be clearly identified at the Armstrong County CBOC.
Closure Date:
6 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Armstrong County CBOC to the contracted processing facility.
Closure Date:
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| 13-01971-245 | Combined Assessment Program Review of the James A. Haley Veterans’ Hospital, Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that all services are included in the review of EHR quality.
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 EOC Committee minutes reflect deficiencies identified on the MH units, corrective actions taken, and tracking of corrective actions to closure.
Closure Date:
4 We recommended that processes be strengthened to ensure that sterile storage rooms are secured at all times and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that staff competency validation results and results of compliance with RME SOPs are reported to the Clinical Executive Board.
Closure Date:
7 We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities have initial training and annual competency validation documented.
Closure Date:
8 We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization have initial training and annual competency validation documented.
Closure Date:
9 We recommended that processes be strengthened to ensure that the SPS eyewash station is checked weekly and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the SPS decontamination area is clean.
Closure Date:
11 We recommended that processes be strengthened to ensure that monthly CS findings summaries and quarterly trend reports are provided to the facility Director consistently and timely.
Closure Date:
12 We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that IC and tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
14 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
Closure Date:
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11259