Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-04192-97 | Combined Assessment Program Review of the San Francisco VA Medical Center, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the patient safety manager be included in the Leadership Board Committee.
Closure Date:
2 We recommended that data about observation bed use be gathered.
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3 We recommended that Emergency Medical Committee code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the code.
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4 We recommended that processes be strengthened to ensure that only sharps are disposed of in sharps containers.
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5 We recommended that processes be strengthened to ensure that Engineering conducts and documents initial safety inspections on non-patient equipment.
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6 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
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7 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
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8 We recommended that a process be established to ensure that HPC consults are acted upon within the timeframe required by local policy.
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9 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
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10 We recommended that processes be strengthened to ensure that home oxygen program patients have active prescriptions and that patients are re-evaluated for home oxygen therapy annually after the first year.
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11 We recommended that processes be strengthened to ensure that competency assessments are completed for all staff authorized to perform oxygen testing.
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12 We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
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| 12-04108-96 | Healthcare Inspection–Appointment Scheduling and Access Patient Call Center, VA San Diego Healthcare System, San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensures that Patient Call Center agents follow policy and procedures for scheduling follow-up appointments and managing non-urgent symptomatic calls.
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2 We recommended that the System Director ensures that timeframes for the primary care teams to follow-up with patients be established.
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| 12-04189-95 | Combined Assessment Program Review of the Oklahoma City VA Medical Center,Oklahoma City, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers initiate actions to address the three identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
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2 We recommended that processes be strengthened to ensure that monthly inspections of automatic dispensing machines are conducted in accordance with local policy.
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3 We recommended that processes be strengthened to ensure that monthly CS inspection findings summaries and quarterly trend reports are consistently provided to the facility Director.
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4 We recommended that the CS Coordinator's duties be included in the position description.
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5 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
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6 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy areas with CS are conducted and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
8 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.
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9 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
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| 11-00711-74 | Healthcare Inspection – Foot Care for Patients with Diabetes and Additional Risk Factors for Amputation | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.
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| 12-04190-89 | Combined Assessment Program Review of the North Florida/South Georgia Veterans Health System, Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the Medical Executive Committee.
Closure Date:
2 We recommended that the local observation bed policy be revised to include all required elements.
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3 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
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4 We recommended that processes be strengthened to ensure that staff perform continuing stay reviews for at least 75 percent of acute care patients.
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5 We recommended that processes be strengthened to ensure that the Emergency Effectiveness Committee reviews individual resuscitation events.
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6 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
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7 We recommended that processes be strengthened to ensure that the blood usage review process includes the results of proficiency testing done by the laboratory.
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8 We recommended processes be strengthened to ensure that the PCCT includes a dedicated nurse and administrative support person.
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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 managers initiate protected peer review for the two identified patients and complete any recommended review actions.
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11 We recommended that processes be strengthened to ensure that all designated staff complete respirator fit testing.
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| 12-00710-85 | Combined Assessment Program Review of the VA New York Harbor Healthcare System,New York, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
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3 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
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4 We recommended that processes be strengthened to ensure that employees who perform glucose POCT receive training and have competency assessed annually.
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5 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
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6 We recommended that processes be strengthened to ensure that patient care areas, public stairways, and restrooms are clean.
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7 We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
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8 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections are conducted, that documentation includes all required elements, and that documentation reflects when deficiencies are resolved and that compliance be monitored.
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9 We recommended that managers take immediate steps to ensure the St. Albans domiciliary is in compliance with EOC standards for cleanliness, safety, and infection prevention and that compliance be monitored.
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10 We recommended that processes be strengthened to ensure that the St. Albans domiciliary access point CCTV is functional at all times.
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11 We recommended that processes be strengthened to ensure that the Brooklyn MH RRTP residential environment provides privacy for veterans.
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12 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
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13 We recommended that processes be strengthened to ensure that discharge instructions are completed for all discharged patients and that they address medications, diet, and the initial follow-up appointment.
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14 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers or required by local policy.
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15 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
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16 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
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17 We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
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18 We recommended that processes be strengthened to ensure that all patients in buprenorphine treatment undergo UDS with the frequency required by local policy.
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19 We recommended that the facility expert panel be convened prior to the next annual staffing plan reassessment and that the panel review all the unit-based expert panels' recommendations.
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20 We recommended that processes be strengthened to ensure that FPPEs are consistently initiated and that results are consistently reported to the PSB and documented in PSB meeting minutes.
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| 12-03355-88 | Inspection of the VA Regional Office, Detroit, Michigan | Review | ||
1 We recommend the Detroit VA Regional Office Director provide training and implement controls to ensure staff follow current Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
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2 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims rating decisions.
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3 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure Veterans Service Center staff follow Veterans Benefits Administration policy on proper establishment of dates of claim.
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4 We recommend the Detroit VA Regional Office Director amend the local Workload Management Plan to include specific requirements for management oversight and review to improve claims processing timeliness.
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5 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations.
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6 We recommend the Detroit VA Regional Office Director develop and implement a plan to monitor the effectiveness of training to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans' entitlement to mental health treatment when denying service connection for mental disorders.
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| 11-04359-80 | Review of VHA's South Texas Veterans Health Care System's Management of Fee Care Funds | Audit | ||
1 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for clinical and fee staff to properly process authorizations for fee care.
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2 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for fee staff to process payments of vendor invoices timely.
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3 We recommended the Director of the South Texas Veterans Health Care System ensure clinical and fee staff receive periodic training on fee care procedures.
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4 We recommended the Director of the South Texas Veterans Health Care System establish independent oversight mechanisms, such as periodic audits or reviews by the Compliance Officer, to ensure that newly established procedures at the South Texas Veterans Health Care System are followed to properly control and manage funds for its fee care program.
Closure Date:
5 We recommended the Director of the Veterans Integrated Service Network establish independent oversight mechanisms, such as periodic audits or reviews, to ensure that procedures for properly controlling and managing fee care program funds are followed at the South Texas Veterans Health Care System.
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| 12-03744-84 | Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas | 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 Staff Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
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 patient care areas are clean and well maintained and clean and dirty supplies are stored separately and that compliance be monitored.
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5 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service and that the facility be well maintained.
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6 We recommended that processes be strengthened to ensure that damaged therapy mats in the Temple division physical therapy clinic are repaired or removed from service.
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7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated MH provider and an administrative support person.
Closure Date:
9 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
10 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:
11 We recommended that managers initiate a protected peer review for the three identified patients and complete any recommended review actions.
Closure Date:
12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
Closure Date:
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| 12-04214-83 | Healthcare Inspection – Emergency Department Evaluation of a Homeless Veteran VA North Texas Health Care System, Dallas, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the facility develops a written SOP for emergency department patient flow and orientation is provided to all emergency department staff and on-call personnel.
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2 We recommended that the Facility Director ensure that EDIS is used as required.
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3 We recommended that the Facility Director ensure that SW services are provided in the emergency department as required.
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14903