Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-02602-79 | Combined Assessment Program Review of the Huntington VA Medical Center,Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that PR analysis summary reports be discussed quarterly at the ECMS and that the discussion be documented in meeting minutes.
Closure Date:
2 We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the ECMS.
Closure Date:
3 We recommended that the facility develop a local policy mandating a Cardiopulmonary Resuscitation Committee.
Closure Date:
4 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.
Closure Date:
5 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
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6 We recommended that processes be strengthened to ensure that smoking occurs in designated areas only.
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7 We recommended that processes be strengthened to ensure that staff are able to locate MSDS for hazardous chemicals used in their areas.
Closure Date:
8 We recommended that the annual staffing plan reassessment process ensures that each unit has a unit-based expert panel and that each panel includes members from all nursing roles.
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9 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
Closure Date:
10 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
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| 12-03740-75 | Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 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 by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
Closure Date:
4 We recommended that the quality control policy for scanning be revised to include image quality, linking of scanned documents to the correct record, and indexing the documents.
Closure Date:
5 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
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6 We recommended that processes be strengthened to ensure that required members from surgery and medicine attend Transfusion Committee meetings.
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7 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
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8 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
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9 We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results for all projects are documented.
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10 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of deficiencies and follow-up actions in response to unsafe conditions identified during inspections.
Closure Date:
11 We recommended that processes be strengthened to ensure that Material Safety Data Sheets for chemicals used in construction sites are located within the construction areas.
Closure Date:
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| 12-02089-60 | Inspection of the VA Regional Office Anchorage, Alaska | Review | ||
1 We recommend the Anchorage VA Regional Office Director develop and implement a plan to monitor proposed disability evaluation reduction processing actions.
Closure Date:
2 We recommend the Anchorage 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.
Closure Date:
3 We recommend the Anchorage VA Regional Office Director develop and implement a plan to assess the effectiveness of training for properly processing traumatic brain injury claims.
Closure Date:
4 We recommend the Anchorage VA Regional Office Director develop and implement controls to ensure management follows the Veterans Benefits Administration's policy and workload management plan for all claims pending for more than 1 year.
Closure Date:
5 We recommend the Anchorage VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations using thorough analysis.
Closure Date:
6 We recommend the Anchorage 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.
Closure Date:
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| 11-01827-36 | Audit of VHA's Physician Staffing Levels for Specialty Care Services | Audit | ||
1 The Office of Inspector General recommends that the Under Secretary for Health approve a plan by the end of FY 2013 that ensures all specialty care services have productivity standards within 3 years.
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2 The Office of Inspector General recommends that the Under Secretary for Health establish productivity standards for at least five specialty care services by the end of FY 2013 and ensure medical facility personnel compare physician workload against these standards.
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3 The Office of Inspector General recommends that the Under Secretary for Health provide medical facility directors with more specific guidance on how to develop staffing plans and ensure medical facility management review them at least annually to ensure optimal efficiency.
Closure Date:
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| 12-03543-73 | Healthcare Inspection – Alleged Patient Safety Deficiencies in the Community Living Center, Canandaigua VA Medical Center, Canandaigua, New York | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director implement procedures to ensure that unit-level reviews of patient falls are patient-specific and address the specific circumstances surrounding the falls.
Closure Date:
2 We recommended that the facility Director implement procedures to ensure that fall prevention interventions are documented in patient care plans.
Closure Date:
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| 12-02352-72 | Healthcare Inspection – Pharmacy and Quality of Care Issues, VA Hudson Valley Health Care System, Castle Point, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Director ensure that the recommendations included in the Administrative Investigation Board report are complied with.
Closure Date:
2 We recommended that the Director ensure that all pharmacy staff be provided ethics training to ensure that employees report unethical behavior without fear of repercussion.
Closure Date:
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| 12-03076-65 | Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
Closure Date:
2 We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
Closure Date:
3 We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
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4 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
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5 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
Closure Date:
6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
7 We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.
Closure Date:
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| 10-01937-63 | Review of Allegations at VA Medical Center, Providence, Rhode Island | Audit | ||
1 We recommended the Veterans Integrated Service Network 1 Director establish controls to ensure the Providence VA Medical Center accurately certifies its Annual Certification of Accounting Records.
Closure Date:
2 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director terminates this contract, and if the services are still needed, recruits and hires under appropriate civil service procedures.
Closure Date:
3 We recommended the Veterans Integrated Service Network 1 Director require the Providence VA Medical Center Director to implement controls ensuring all fund obligations are accompanied by supporting documentation to justify the obligation as required by law.
Closure Date:
4 We recommended the Veterans Integrated Service Network 1 Director ensure service contracts are awarded based on adequate competition or, if competition is not feasible, are supported by limited or sole-source justifications as required by Federal Acquisition Regulation.
Closure Date:
5 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director establishes controls to ensure appropriated funds are used only for the intended purpose of the appropriation.
Closure Date:
6 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the Designated Education Officer to obtain and oversee annual rate changes for disbursing agreements.
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7 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director charges the Chief of Facilities Management Service 25 days of annual leave because his absence was not supported by an approved written justification.
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8 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director institutes a control that ensures at the point timecards are certified appropriate documentation in support of approved excused absences is in place.
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9 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the property owner to make necessary repairs to alleviate future water leaks and damage, and if not repaired, moves employees in the affected areas to a more suitable workspace.
Closure Date:
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| 12-03346-69 | Review of VHA's Minor Construction Program | Audit | ||
1 We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
Closure Date:
2 We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
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3 We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
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4 We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
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5 We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
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6 We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
Closure Date:
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| 12-03741-61 | Combined Assessment Program Review of the VA Maine Healthcare System,Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
Closure Date:
3 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 by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
Closure Date:
4 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
Closure Date:
5 We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
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6 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
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14903