Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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 | ||
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 tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that the Credentials Committee of the Executive Board for Clinical Affairs grants privileges consistent with the services provided at the Lynchburg and Wytheville CBOCs.
Closure Date:
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| 12-02223-98 | Audit of NCA's Internal Gravesite Review of Headstone and Marker Placement | Audit | ||
1 We recommended the Under Secretary for Memorial Affairs ensure implementation of the three recommendations in the July 5, 2012, Management Advisory Memorandum.
Closure Date:
2 We recommended the Under Secretary for Memorial Affairs ensure management take corrective actions regarding the additional 153 errors identified in this report, including the notification of congressional committees and contacting families when possible.
Closure Date:
3 We recommended the Under Secretary for Memorial Affairs implement procedures to assess cemetery size and cemetery director responsibility to ensure adequate time and resources are available before conducting future gravesite reviews.
Closure Date:
4 We recommended the Under Secretary for Memorial Affairs implement controls, including a certification, to ensure gravesite layout maps are routinely updated, accurate, and provided to the cemeteries.
Closure Date:
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| 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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| 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:
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| 12-03745-93 | Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the Medical Executive Committee.
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 the facility ensure compliance with VHA policy requiring an intraoperative x-ray for incorrect sharp counts.
Closure Date:
5 We recommended that processes be strengthened to ensure that CS quarterly trend reports are consistently provided to the facility Director.
Closure Date:
6 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated 0.25 FTE MH provider and that local policy be updated to reflect this requirement.
Closure Date:
8 We recommended that the facility establish a policy to reduce the fire hazards of smoking associated with oxygen treatment.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
10 We recommended that all members of the facility expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
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| 11-04376-81 | Review of VBA’s Transition to a Paperless Claims Processing Environment | Audit | ||
1 We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology broaden the types of claims tested at additional sites to provide assurance that the range of VBA functionality and processing requirements can be met through VBMS.
Closure Date:
2 We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology establish a plan with milestones to resolve the system issues to ensure system testing does not adversely impact and add to the existing claims processing backlog.
Closure Date:
3 We recommend the Under Secretary for Benefits ensure development of a detailed plan, including costs associated with the long-term scanning solution, so that transformation efforts do not adversely impact and add to the existing claims processing backlog.
Closure Date:
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| 12-02476-103 | Healthcare Inspection – Mid-Level Provider Oversight, George E. Wahlen VA Medical Center, Salt Lake City, UT | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director establish an equivalent process to Focused Professional Practice Evaluations and Ongoing Professional Practice Evaluations for mid-level scope of practice reviews.
Closure Date:
2 We recommended that the facility Director ensure that the mid-level Professional Standards Board forwards their recommendations for the granting of scopes of practice to the Medical Executive Committee for review.
Closure Date:
3 We recommended that all staff in the Intensive Care Unit, including the attending physicians, receive training on adverse event reporting.
Closure Date:
4 We recommended that systems be strengthened to ensure that all Intensive Care Unit near misses and adverse events are reported.
Closure Date:
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14903