Recommendations
1324
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01351-296 | Healthcare Inspection – Alleged Sterile Processing Service Deficiencies, VA Puget Sound Health Care System, Seattle, Washington | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that Sterile Processing Service has a process in place to identify single-use devices and mitigate the risk of single-use devices being resterilized.
Closure Date:
2 We recommended that the System Director ensure that processes be strengthened to ensure that Sterile Processing Service staff competency records are well organized and that managers are able to readily determine the current competence of each person on each task.
Closure Date:
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| 12-04326-275 | Inspection of VA Regional Office Muskogee, Oklahoma | Review | ||
1 We recommend the Muskogee VA Regional Office Director conduct a review of the 304 temporary 100 percent disability evaluations remaining from our inspection universe.
Closure Date:
2 We recommend the Muskogee VA Regional Office Director provide refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of the training.
Closure Date:
3 We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure accurate second-signature reviews of traumatic brain injury claims.
Closure Date:
4 We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure Rating Veterans Service Representatives correctly address Gulf War veterans' entitlement to mental health treatment as required.
Closure Date:
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| 13-00026-302 | Community Based Outpatient Clinic Reviews at Chillicothe VA Medical Center, Chillicothe, OH | 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 administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that a written inventory of hazardous materials is maintained.
Closure Date:
5 We recommended that all identified EOC deficiencies are tracked, trended, and corrected.
Closure Date:
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| 13-01625-273 | Inspection of VA Regional Office Newark, New Jersey | Review | ||
1 We recommend the Newark VA Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits.
Closure Date:
2 We recommend the Newark VA Regional Office Director develop and implement a plan to review the 149 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommend the Newark VA Regional Office Director develop and implement a plan to ensure effective second-signature reviews of traumatic brain injury claims decisions.
Closure Date:
4 We recommend the Newark 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 within the VA Regional Office's jurisdiction.
Closure Date:
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| 13-00993-274 | Inspection of VA Regional Office Albuquerque, New Mexico | Review | ||
1 We recommend the Albuquerque VA Regional Office Director conduct a review of the 190 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the Albuquerque VA Regional Office Director conduct refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
Closure Date:
3 We recommend the Albuquerque VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to obtain the evidence required to support traumatic brain injury evaluations.
Closure Date:
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| 12-01899-238 | Audit of Foreclosed Property Management Contractor Oversight | Audit | ||
1 We recommended the Under Secretary for Benefits ensure the Veterans Benefits Administration's foreclosed property management contractor provides vendor invoices to substantiate expenses claimed by the contractor prior to reimbursement by Loan Guaranty Service.
Closure Date:
2 We recommended the Under Secretary for Benefits determine whether it is cost effective to initiate recovery of improper payments identified in our audit.
Closure Date:
3 We recommended the Under Secretary for Benefits develop policies that require Loan Guaranty Service to report maintenance exceptions to its foreclosed property management contractor when identified and follow up to ensure correction.
Closure Date:
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| 13-01975-292 | Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
2 We recommended that processes be strengthened to ensure that floors in patient care areas are clean and that compliance be monitored.
3 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
4 We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive annual competency assessments.
5 We recommended that processes be strengthened to ensure that RME standard operating procedures are consistent with manufacturers’ instructions.
6 We recommended that processes be strengthened to ensure that bi-weekly inventories of automated dispensing machines are consistently conducted and that compliance be monitored.
7 We recommended that processes be strengthened to ensure that end of shift counts for non-automated dispensing units are completed daily and that compliance be monitored.
8 We recommended that the inspection checklist be amended to include all required items and that processes be strengthened to ensure that inspectors perform drug destruction and audit trail verification and that compliance be monitored.
9 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated social worker and a dedicated psychologist or other MH provider.
10 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.
11 We recommended that processes be strengthened to ensure that acute care staff consistently document location, stage, risk scale score, and/or date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
12 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 being discharged and that compliance be monitored.
13 We recommended that processes be strengthened to ensure that the dietary screening and assessment of patients with pressure ulcers is consistent with facility policy and that compliance be monitored.
14 We recommended that the facility fully implement the nurse staffing methodology.
15 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
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| 13-01973-288 | Combined Assessment Program Review of the Fargo VA Health Care System, Fargo, North Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired LIPs are consistently initiated.
Closure Date:
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased care during which diagnostic tests are performed are consistently scanned into EHRs.
Closure Date:
3 We recommended that the facility develop instructions for inspections of automated dispensing machines and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections and annually and that all CS inspectors receive annual updates and refresher training and that compliance be monitored.
Closure Date:
5 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 a hard copy order for at least 2 randomly selected dispensing activities is verified and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that inspectors consistently verify the number of prescription pads and that 72-hour inventories of the main vault are consistently performed and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that physical counts of all pharmacy drugs are completed during the 1st month of the quarter and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that inspectors verify hard copy prescriptions for 10 percent of the schedule II drugs dispensed in the outpatient pharmacy and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that drugs held for destruction are consistently compared with the Destruction File Holding Report, that inspectors consistently verify drug destructions are completed at least quarterly, and that inspectors ensure audit trails for destruction of 10 randomly selected drugs are consistently verified and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that inspector competencies are documented and that inspectors date and initial inspection documents at the time of the inspection and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and the date the pressure ulcer was acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
13 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:
14 We recommended that processes be strengthened to ensure that documentation of construction site inspections includes time of inspections, type of corrective action for identified deficiencies, and date and time of corrective actions.
Closure Date:
15 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in ICC minutes.
Closure Date:
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| 13-00026-280 | Community Based Outpatient Clinic Reviews at Philadelphia VA Medical Center, Philadelphia, PA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
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| 13-00026-293 | Community Based Outpatient Clinic Reviews at VA Central California Health Care System, Fresno, CA | 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 document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
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11259