Recommendations
1332
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03038-145 | Healthcare Inspection – Excessive Length of Stay and Quality of Care Issues in the Emergency Department, William Jennings Bryan Dorn VA Medical Center, Columbia, SC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director identify a reporting structure for Emergency Department Integration Software data and ensure that mandated quarterly reports containing and utilizing Emergency Department Integration Software data are provided.
Closure Date:
2 We recommended that the Facility Director ensure that planned actions to address patient flow (hire additional providers and extend hours for the non-urgent area) are implemented and that patient flow outcomes are monitored.
Closure Date:
3 We recommended that the Facility Director ensure that Emergency Department providers and other clinical and administrative staff receive training on the use of Emergency Department Integration Software delay reasons and that accuracy is monitored.
Closure Date:
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| 12-02317-144 | Healthcare Inspection - Improper Conduct During Merit Review Proceedings | Hotline Healthcare Inspection | ||
| 13-00026-137 | Community Based Outpatient Clinic Reviews at San Francisco VA Medical Center, San Francisco, CA | Comprehensive Healthcare Inspection Program | ||
| 12-04188-140 | Combined Assessment Program Review of the Battle Creek VA Medical Center, Battle Creek, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that senior leaders routinely discuss the facility's Inpatient Evaluation Center data and ensure the discussion are documented in the minutes of a senior-level committee.
Closure Date:
2 We recommended that the facility's local observation bed policy be revised to include all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that conversions from observation bed status to acute admissions are consistently 30 percent or less.
Closure Date:
4 We recommended that processes be strengthened to ensure that continued stay reviews are completed on at least 75 percent of patients in acute beds.
Closure Date:
5 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
6 We recommended that the quality control policy for scanning includes indexing the documents, linking scanned documents to the correct record, and image quality.
Closure Date:
7 We recommended that processes be strengthened to ensure that blood/transfusion reviews are consistently completed at least quarterly.
Closure Date:
8 We recommended that processes be strengthened to ensure that tables used for women's health examinations are placed with the foot facing away from the door or are shielded by privacy curtains.
Closure Date:
9 We recommended that the physical therapy clinic have exit signage.
Closure Date:
10 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:
11 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:
12 We recommended that processes be strengthened to ensure that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that the PCCT includes a 0.25 full-time employee equivalent physician.
Closure Date:
14 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
15 We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain the need to provide educational information on the hazards of smoking while oxygen is in use at least every 6 months after the initial delivery.
Closure Date:
16 We recommended that facility implement the mandated staffing methodology for nursing personnel.
Closure Date:
17 We recommended that managers initiate protected PR for the one identified patient and complete any recommended review actions.
Closure Date:
18 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:
19 We recommended that processes be strengthened to ensure that Material Safety Data Sheet information for hazardous materials is maintained within the construction area.
Closure Date:
20 We recommended that processes be strengthened to ensure that contract workers wear VA-issued identification badges.
Closure Date:
| ||||
| 12-02612-141 | Healthcare Inspection – Alleged Quality of Care and Problems with Services, VA Gulf Coast Veterans Health Care System, Biloxi, MS | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that a quality of care review is conducted with specific attention to the deficiencies identified in this report.
Closure Date:
2 We recommended that the Facility Director strengthen processes to address patient complaints regarding the automated telephone system at the Mobile CBOC.
Closure Date:
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| 13-00276-135 | Combined Assessment Program Review of the Charles George VA Medical Center, Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
| 12-04241-138 | Review of VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2012 | Audit | ||
1 We recommended the Under Secretary for Health implement its corrective action plan, as described in the Performance and Accountability Report, for reducing improper payments in the Non-VA Care Fee program.
Closure Date:
2 We recommended the Under Secretary for Health develop achievable reduction targets for the Non-VA Care Fee program.
Closure Date:
3 We recommended the Under Secretary for Health implement an improper payments estimation methodology that will achieve the required statistical precision for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.
Closure Date:
4 We recommended the Under Secretary for Benefits develop and implement a statistically valid estimation methodology for the Compensation, Pension, and Vocational Rehabilitation and Employment programs for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.
Closure Date:
5 We recommended the Under Secretary for Benefits develop a process to collect and report the required improper payments recapture information.
Closure Date:
6 We recommended the Executive in Charge for the Office of Management and Chief Financial Officer complete planned activities to improve compliance with the Improper Payments Elimination and Recovery Act and use this information to develop and issue additional guidance.
Closure Date:
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| 13-00277-134 | Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Board.
Closure Date:
2 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.
Closure Date:
3 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that the facility is well maintained and that compliance be monitored and that damaged furniture in patient care areas be repaired or removed from service.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated correctly when opened.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient privacy is maintained in the PM&R clinic during potentially exposing treatment modalities.
Closure Date:
7 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility and unit-based expert panel members.
Closure Date:
8 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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| 11-02585-129 | Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health ensure that VHA program officials provide additional guidance on what constitutes disruptive behavior and establish common terminology.
Closure Date:
2 We recommended that the Under Secretary for Health ensure that VHA program officials develop guidelines for what information VHA facilities should document regarding disruptive incidents and where this information should be documented.
Closure Date:
3 We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents.
Closure Date:
4 We recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents.
Closure Date:
5 We recommended that the Under Secretary for Health ensure that VHA facilities implement procedures to ensure more timely assignment of Category I PRFs.
Closure Date:
| ||||
| 12-02802-111 | Review of Alleged Transmission of Sensitive VA Data Over Internet Connections | Audit | ||
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