Recommendations
829
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02071-02 | Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Resuscitation Services Committee reviews each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
2 We recommended that processes be strengthened to ensure that Environment of Care Committee minutes and the environment of care rounds database accurately reflect whether deficiencies were resolved.
Closure Date:
3 We recommended that processes be strengthened to ensure that patient care areas and public restrooms are clean and free from offensive odors and walls, counters, floors, and furnishings in these areas are in good repair and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that equipment items receive appropriate maintenance and preventive maintenance and electrical inspections stickers are current and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and medications are secured at all times and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake and that patients are provided with printed stroke education upon discharge and that compliance be monitored.
Closure Date:
11 We recommended that the facility collect and report to the Medical Executive Committee the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff include restorative nursing goals and interventions in residents’ care plans and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete required restorative nursing interventions and document the interventions with the frequency established by facility policy, that documentation reflects progress toward goals and reasons why interventions were not provided, and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion.
Closure Date:
15 We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and are signed and dated by a Level 2 magnetic resonance imaging personnel prior to the scan and that compliance be monitored.
Closure Date:
16 We recommended that facility policy be revised to correct contradictory elements and to be consistent with VHA policy.
Closure Date:
17 We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted to determine the risk of tuberculosis transmission to contractors.
Closure Date:
18 We recommended that processes be strengthened to ensure that construction site inspections are conducted at the required frequency and that inspections contain all elements required by VHA policy.
Closure Date:
19 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
Closure Date:
20 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
Closure Date:
21 We recommended that processes be strengthened to ensure that all construction projects comply with VHA policy requirements.
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| 14-02100-271 | Inspection of VA Regional Office Portland, Oregon | Review | ||
1 We recommended the Portland VA Regional Office Director implement a plan to ensure staff timely process rating reductions for temporary 100 percent disability evaluations.
Closure Date:
2 We recommended the Portland VA Regional Office Director conduct a review of the 364 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommended the Portland VA Regional Office Director assess the effectiveness of training for special monthly compensation and ancillary benefits claims.
Closure Date:
4 We recommended the Under Secretary for Benefits implement a national plan for an additional level of review for special monthly compensation and ancillary benefits claims.
Closure Date:
5 We recommended the Portland VA Regional Office Director implement a plan, and assess the effectiveness of the plan, to ensure adequate and continuous oversight of completing Systematic Analyses of Operations.
Closure Date:
6 We recommended the Portland VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
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| 14-01688-303 | Inspection of VA Regional Office Salt Lake City, Utah | Review | ||
| 14-00925-299 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the parent facility includes staff at the Northampton County and Williamsport CBOCs in required education, training, planning, and participation in annual disaster exercises.
Closure Date:
2 We recommended that the parent facility documents Emergency Management Preparedness-specific training completed for the Northampton County and Williamsport CBOCs' clinical providers.
Closure Date:
3 We recommended that the parent facility's Emergency Management Committee evaluates the Northampton County and Williamsport CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic staff consistently document the offer offurther treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
6 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
7 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 14-03212-295 | Healthcare Inspection – Emergency Department Concerns, Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas | Hotline Healthcare Inspection | ||
1 We recommended that the Eastern Kansas Health Care System Director ensure that all patients who present to the Eastern Kansas Health Care System Emergency Department requesting an examination or treatment receive a medical screening examination and that compliance is monitored.
Closure Date:
2 We recommended that the Eastern Kansas Health Care System Director ensure Leavenworth VAMC Emergency Department and Primary Care Clinic nursing staff document required assessments and that compliance is monitored.
Closure Date:
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| 14-02064-252 | Combined Assessment Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas | Comprehensive Healthcare Inspection Program | ||
| 14-04003-298 | Review of Alleged Data Manipulation at the VA Regioinal Office Houston, TX | Audit | ||
1 We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear, change, or cancel controls for claims.
Closure Date:
2 We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
Closure Date:
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| 13-04005-296 | Healthcare Inspection – Out of Operating Room Airway Management Concerns, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the facility’s out of operating room airway management policy is updated to include all Veterans Health Administration requirements.
Closure Date:
2 We recommended that the Facility Director ensure that processes be strengthened to complete out of operating room airway management training and competency requirements as outlined by Veterans Health Administration and local policies.
Closure Date:
3 We recommended that the Facility Director ensure that processes be strengthened to provide out of operating room airway management coverage as required.
Closure Date:
4 We recommended that the Facility Director ensure that highly portable video laryngoscope equipment is immediately available
Closure Date:
5 We recommended that the Facility Director ensure that analysis of the five patient care events identified in this report is completed as required.
Closure Date:
6 We recommended that the Facility Director ensure that the scopes of practice are updated for non-licensed independent practitioners who perform out of operating room airway management.
Closure Date:
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| 14-00927-293 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Long Beach Healthcare System, Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic alarms are tested, and testing is documented at the Santa Ana CBOC.
Closure Date:
2 We recommended that the parent facility's Emergency Management Committee evaluate emergency preparedness activities, participation in annual disaster exercise, and staff training/education related to emergency preparedness requirements at the Santa Ana CBOC.
Closure Date:
3 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that staff document that medication reconciliation is completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 14-02889-310 | Inspection of VA Regional Office White River Junction, Vermont | Review | ||
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