Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00273-147 | Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Clinical Safety Committee reviews each code episode and that code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the code.
Closure Date:
2 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
3 We recommended that facility managers develop and implement a policy that details quality control for scanning into EHRs.
Closure Date:
4 We recommended that the Transfusion Review Committee meets quarterly and that processes be strengthened to ensure that the blood usage review process includes consistent reporting of data and the results of proficiency testing and peer reviews.
Closure Date:
5 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution for outcomes from resuscitation, EHR reviews, blood/transfusion reviews, and system redesign.
Closure Date:
6 We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Clinical Safety Committee minutes document those actions.
Closure Date:
7 We recommended that facility managers develop and implement a policy that details cleaning of equipment between patients and that compliance with the policy be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that identified women's health-related deficiencies are tracked to closure.
Closure Date:
9 We recommended that the facility implement a PCCT that complies with VHA requirements.
Closure Date:
10 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
11 We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
Closure Date:
12 We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
Closure Date:
13 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
14 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 is documented.
Closure Date:
15 We recommended that processes be strengthened to ensure that all new home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order.
Closure Date:
16 We recommended that processes be strengthened to ensure that the home oxygen vendor is notified when a patient is identified by the facility as being a high-risk smoker.
Closure Date:
17 We recommended that nursing managers implement all the required processes for the staffing methodology for nursing personnel.
Closure Date:
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| 13-00026-137 | Community Based Outpatient Clinic Reviews at San Francisco VA Medical Center, San Francisco, CA | 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 screen patients for tetanus vaccinations.
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 pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that panic alarms in high-risk areas are tested and that testing is documented.
Closure Date:
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| 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:
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| 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 | ||
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 processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated.
Closure Date:
3 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
4 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
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 of PRs when transfusions did not meet criteria.
Closure Date:
6 We recommended that processes be strengthened to ensure that documentation for blood product transfusions includes applicable laboratory/clinical results post-transfusion and the assessment of outcome.
Closure Date:
7 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in utilization management, resuscitation, and blood/transfusion utilization reviews.
Closure Date:
8 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to housekeeping deficiencies identified during EOC rounds are tracked to closure.
Closure Date:
9 We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Committee minutes document those actions.
Closure Date:
10 We recommended that processes be strengthened to ensure that expired commercial supplies are removed from sterile storage rooms and treatment areas.
Closure Date:
11 We recommended that processes be strengthened to ensure that After-Installation Checklists are completed for all ceiling lifts in the PT/OT/KT clinic areas.
12 We recommended that processes be strengthened to ensure that damaged chairs in the PT/OT/KT clinic areas are repaired or removed from service.
Closure Date:
13 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
14 We recommended that processes be strengthened to ensure that home oxygen program patients receive a timely annual re-evaluation after the first year.
Closure Date:
15 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
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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| 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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| 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:
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| 12-02802-111 | Review of Alleged Transmission of Sensitive VA Data Over Internet Connections | Audit | ||
2 We recommend the Assistant Secretary for Information and Technology require that OIT personnel complete specialized training emphasizing the importance of encrypting sensitive VA data transmitted across public Internet connections.
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| 12-04604-127 | Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Medical Emergency Committee collects data that measures performance in responding to resuscitation events and that code reviews include screening for clinical issues prior to codes that may have contributed to the occurrence of the codes.
Closure Date:
2 We recommended that the quality control policy for scanning includes the linking of scanned documents to the correct EHR and that processes be strengthened to ensure that the review of EHR quality includes all services and that EHR quality review reports are analyzed.
Closure Date:
3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicate problems or opportunities for improvement are evaluated for effectiveness in Geriatric and Extended Care Performance Improvement Council data and the Patient Flow Coordination Collaborative.
Closure Date:
4 We recommended that facility managers correct the identified cleanliness and environmental safety issues and that the EOC Committee documents progress in EOC Committee minutes.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and discarded when expired.
Closure Date:
6 We recommended that managers initiate actions to address the identified physical security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
7 We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is reconciled and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
Closure Date:
9 We recommended that the CS Coordinator's duties be included in his or her position description.
Closure Date:
10 We recommended that processes be strengthened to ensure that all CS inspectors are appointed in writing by the facility Director prior to assuming their duties.
Closure Date:
11 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates.
Closure Date:
12 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS include all required elements and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated physician and administrative support person.
Closure Date:
14 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
15 We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the Computerized Patient Record System.
Closure Date:
16 We recommended that processes be strengthened to ensure that patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensures that all required staff are members of the unit-based and facility expert panels.
Closure Date:
18 We recommended that members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
19 We recommended that the facility complete the staffing methodology process.
Closure Date:
20 We recommended that the facility establish a construction safety program with a multidisciplinary committee that effectively monitors infection control, safety, and security issues during construction and renovation activities in accordance with VHA requirements.
Closure Date:
21 We recommended that all identified infection control, safety, and security deficiencies for the Building 7 construction project be corrected and that compliance be monitored. VA
Closure Date:
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14903