Recommendations
782
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-01315-90 | Sterile Processing Service Deficiencies and Leaders’ Response at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Carl Vinson VA Medical Center Director ensures that the Sterile Processing Services chief conducts comprehensive staff competency assessments for the reprocessing of reusable medical equipment, and monitors for compliance.
Closure Date:
2 The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.
3 The Carl Vinson VA Medical Center Director evaluates and ensures that Sterile Processing Services maintains a safe and clean environment in all areas where decontamination, sterilization, or clean and sterile storage of reusable medical equipment are performed, and monitors for compliance.
Closure Date:
4 The Carl Vinson VA Medical Center Director develops an action plan for remediation of the location and use of the training room adjacent to Sterile Processing Services’ clean and sterile storage area, and monitors for compliance.
Closure Date:
5 The Carl Vinson VA Medical Center Director ensures that clinic areas, including radiology, have or share a designated soiled utility room as required by Veterans Health Administration policy, and monitors for compliance.
Closure Date:
6 The Carl Vinson VA Medical Center Director ensures that Sterile Processing Service standard operating procedures for reusable medical equipment are developed, updated consistent with manufacturer’s instructions for use, disseminated, and available at the point of use, and monitors for compliance.
Closure Date:
7 The Veterans Integrated Service Network Director reviews the facility’s Sterile Processing Service water management program and takes action as necessary to ensure compliance with Veterans Health Administration guidance, and monitors for compliance.
Closure Date:
8 The Carl Vinson VA Medical Center Director ensures that the facility Water Working Group submits critical water system test results to the Veterans Integrated Service Network Sterile Processing Services Management Board, as required, and monitors for compliance.
Closure Date:
9 The Veterans Integrated Service Network Director ensures all critical water system test results are reviewed by the Veterans Integrated Service Network Sterile Processing Services Management Board, corrective action is taken when appropriate, and all corrective actions are reported to the National Program Office for Sterile Processing, and monitors for compliance.
Closure Date:
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| 22-03157-95 | Comprehensive Healthcare Inspection of the Manchester VA Medical Center in New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the Medical Executive Council reviews results of professional practice evaluations.
Closure Date:
2 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.
Closure Date:
3 The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer provides oversight of the medical center’s privileging process.
Closure Date:
4 The Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.
Closure Date:
5 The Medical Center Director ensures staff keep patient care areas clean and safe.
Closure Date:
6 The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
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| 22-03166-88 | Comprehensive Healthcare Inspection of the Aleda E. Lutz VA Medical Center in Saginaw, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff complete individual root cause analyses for all adverse patient safety events with an actual or potential safety assessment code score of 3.
Closure Date:
2 The Chief of Staff ensures service chiefs maintain sufficient data for licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
3 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 23-00015-86 | Comprehensive Healthcare Inspection of the White River Junction VA Medical Center in Vermont | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff complete a minimum of eight patient safety analyses each year.
Closure Date:
2 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Focused and Ongoing Professional Practice Evaluations.
Closure Date:
3 The Chief of Staff ensures service chiefs complete licensed independent practitioners’ Ongoing Professional Practice Evaluations on a regular basis.
Closure Date:
4 The Medical Center Director ensures the suicide prevention coordinators report suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
5 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-00018-83 | Comprehensive Healthcare Inspection of the Minneapolis VA Health Care System in Minnesota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-00017-81 | Comprehensive Healthcare Inspection of the Alaska VA Healthcare System in Anchorage | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.
Closure Date:
2 The Executive Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.
Closure Date:
3 The Executive Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00010-84 | Comprehensive Healthcare Inspection of the James A. Haley Veterans’ Hospital in Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures staff keep areas used by patients clean and orderly.
Closure Date:
2 The Associate Director ensures staff store clean and dirty equipment and supplies separately.
Closure Date:
3 The Associate Director ensures staff place all examination tables with the foot facing away from the door.
Closure Date:
4 The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
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| 23-00153-41 | Rating Schedule Updates for Hip and Knee Replacement Benefits Were Not Consistently Applied | Review | ||
1 Conduct a review of the convalescence claims for hip and knee replacements and resurfacing completed from February 7, 2021, through August 31, 2022, and take appropriate actions to correct convalescence periods and ensure monetary benefits are accurate.
2 Implement a plan to assist employees with determining the effective date, incorporating the initial month under 38 C.F.R. § 4.30, and calculating the duration of convalescence.
Closure Date:
3 Develop implementation procedures to include monitoring the accuracy of claims processing when the related rating schedule has been revised.
Closure Date:
4 Supplement training on the rating schedule updates to include how to apply the changes to help ensure comprehension.
Closure Date:
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| 22-04038-82 | Comprehensive Healthcare Inspection of the Battle Creek VA Medical Center in Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 22-02113-75 | Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The North Las Vegas VA Medical Center Director reviews the community care coordination program, identifies deficiencies, and takes actions as warranted to ensure compliance with the Veterans Health Administration Field Guidebook, including training and completion of all care coordination responsibilities for patients discharged from a community hospital stay paid for by the VA.
Closure Date:
2 The North Las Vegas VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the primary care processes, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including response time to patients’ scheduling requests and availability of same-day access for face-to-face and telephone encounters.
Closure Date:
3 The Sierra Pacific Network Director in conjunction with the Chief Medical Officer continues the review of the complete course of care provided by the Veterans Integrated Service Network physician for the patient, including the delivery of anticoagulants, and ability to access scanned documents in the electronic health record, and takes actions as warranted.
Closure Date:
4 The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief and the Primary Care Service chief, review the suicide prevention training program to ensure compliance with Veterans Health Administration policies, including reporting requirements following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.
Closure Date:
5 The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief, reviews the suicide prevention coordinators’ compliance with Veterans Health Administration policies, including actions required to complete a behavioral health autopsy and family interview tool contact form following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.
Closure Date:
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11259