Recommendations
1324
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00432-217 | Combined Assessment Program Review of the Spokane VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
| 13-01741-215 | Combined Assessment Program Summary Report - Evaluation of Colorectal Cancer Screening and Follow-Up in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Closure Date:
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| 12-04328-211 | Inspection of VA Regional Office Wilmington, Deleware | Review | ||
1 We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and timely schedule medical reexaminations when the reminder notifications generate.
Closure Date:
2 We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits when appropriate.
Closure Date:
3 We recommend the Wilmington VA Regional Office Director conduct a review of the 57 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
4 We recommend the Wilmington 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 under the VA Regional Office's jurisdiction.
Closure Date:
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| 13-00026-212 | Community Based Outpatient Clinic Reviews at Oklahoma City VA Medical Center, Oklahoma City, OK | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are strengthened 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 processes are strengthened to 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 managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the PSB grants setting-specific clinical privileges for all providers at the Ardmore and Enid CBOCs.
Closure Date:
6 We recommended that handicapped parking spaces at the Enid CBOC meet ADA requirements for parking space identification.
Closure Date:
7 We recommended that restroom access is improved for disabled veterans at the Ardmore and Enid CBOCs.
Closure Date:
8 We recommended that laboratory specimens are secured during transport from the Ardmore and Enid CBOCs to the parent facility.
Closure Date:
9 We recommended that the IT server closets are maintained according to IT safety and security standards at the Ardmore and Enid CBOCs.
Closure Date:
10 We recommended that managers ensure that an AED is available at the Enid CBOC.
Closure Date:
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| 13-00026-207 | Community Based Outpatient Clinic Reviews at North Florida/South Georgia Veterans Health System, Gainesville, FL | Comprehensive Healthcare Inspection Program | ||
| 13-00376-201 | Combined Assessment Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the results of FPPEs for newly hired LIPs are consistently reported to the ECOMS.
Closure Date:
2 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed.
Closure Date:
4 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services
Closure Date:
5 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient care equipment is consistently cleaned between patient use.
Closure Date:
7 We recommended that processes be strengthened to ensure that gloves in all sizes and gowns are available in the therapy clinic areas.
Closure Date:
8 We recommended that processes be strengthened to ensure that inspectors are sufficiently rotated in inspection assignments and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that inspectors do not participate in inspections beyond their 3-year appointment expiration date and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated nurse, social worker, and administrative support person and a 0.25 FTE psychologist or other MH provider.
Closure Date:
11 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:
12 We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
Closure Date:
13 We recommended that unit 134-3Cs nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
14 We recommended that managers initiate protected PR for the identified patient and complete any recommended review actions.
Closure Date:
15 We recommended that processes be strengthened to ensure that routine construction site inspections are conducted by the required CSC members, include all required elements, and are documented.
Closure Date:
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| 13-00889-206 | Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia | Comprehensive Healthcare Inspection Program | ||
| 13-00888-203 | Combined Assessment Program Review of the VA Southern Nevada Healthcare System, Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from PRs are consistently completed and reported to the PR Committee.
Closure Date:
2 We recommended that the facility monitor compliance with the recently implemented observation bed use policy.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
4 We recommended that managers initiate actions to address identified deficiencies in the PCC pharmacies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
5 We recommended that the facility develop instructions for inspecting automated dispensing machines that include all VHA requirements and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
Closure Date:
7 We recommended that processes be strengthened to ensure that the CS Coordinator only performs occasional inspections and that a sufficient number of CS inspectors are appointed to conduct the monthly inspections.
Closure Date:
8 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
9 We recommended that the facility fully implement the nurse staffing methodology.
Closure Date:
10 We recommended that managers initiate protected PR for the one identified patient and complete any recommended review actions.
Closure Date:
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| 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 | ||
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