Recommendations
1324
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03854-114 | Community Based Outpatient Clinic Reviews at Iowa City VA Health Care System, Iowa City, IA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined 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 pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that the FPPE review for the Cedar Rapids CBOC providers is included in the Clinical Executive Board meeting minutes.
Closure Date:
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| 12-03852-109 | Community Based Outpatient Clinic Reviews at Spokane VA Medical Center, Spokane, WA | Comprehensive Healthcare Inspection Program | ||
| 12-03850-112 | Community Based Outpatient Clinic Reviews at Charles George VA Medical Center, Asheville, NC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
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| 12-03852-110 | Community Based Outpatient Clinic Reviews at Alaska VA Healthcare System, Anchorage, AK | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that fire and life safety inspections are conducted annually at the Kenai and Mat-Su CBOCs.
Closure Date:
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| 12-03850-106 | Community Based Outpatient Clinic Reviews at Salem VA Medical Center, Salem, VA | Comprehensive Healthcare Inspection Program | ||
| 12-01556-108 | Healthcare Inspection – Alleged Quality of Care Issues and Communication Lapses, Washington DC VA Medical Center, Washington, DC | Hotline Healthcare Inspection | ||
1 We recommended that the Medical Center Director consult with Regional Counsel regarding possible institutional disclosure to the patient's family for whom quality of care concerns were identified.
Closure Date:
2 We recommended that the Medical Center Director take action to improve oversight of PA practice activities in the urology clinic.
Closure Date:
3 We recommended that the Medical Center Director conduct a peer review of the care identified in this report.
Closure Date:
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| 12-04605-107 | Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure that actions implemented to address high-risk areas are documented in Infection Control Committee minutes.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened.
Closure Date:
6 We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education be documented.
Closure Date:
7 We recommended that unit 4C North's expert panel and CLC unit First Floor's expert panel reassess the inpatient staffing needed following the required processes.
Closure Date:
8 We recommended that the annual staffing plan reassessment process ensure that the facility expert panel includes all required members.
Closure Date:
9 We recommended that managers initiate a protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
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| 12-02223-98 | Audit of NCA's Internal Gravesite Review of Headstone and Marker Placement | Audit | ||
| 11-00336-292 | Audit of VHA's Beneficiary Travel Program | Audit | ||
1 We recommend the Under Secretary for Health develop mechanisms to ensure that approved Beneficiary Travel Program reimbursement data are reconciled with payment data.
Closure Date:
2 We recommend the Under Secretary for Health implement training necessary to ensure the Veterans Health Administration staff properly code Beneficiary Travel Program expenses entered into the Financial Management System.
Closure Date:
3 We recommend the Under Secretary for Health establish procedures to mitigate the risk of making duplicate payments on approved travel reimbursements.
Closure Date:
4 We recommend the Under Secretary for Health implement procedures to verify the accuracy of beneficiary addresses at the time of request for beneficiary travel.
Closure Date:
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| 12-03850-105 | Community Based Outpatient Clinic Reviews at Durham VA Medical Center, Durham, NC | 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 document all required pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
| ||||
11259