Recommendations
716
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-03655-84 | Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah | 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 completed.
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 continuing stay reviews are consistently performed on patients in acute beds and that they are completed on at least 75 percent of acute care patients.
Closure Date:
4 We recommended that processes be strengthened to ensure that members from Surgery and Anesthesia Services attend Blood Transfusion Committee meetings.
Closure Date:
5 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that expired medications and supplies are removed from patient care areas and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
Closure Date:
9 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:
10 We recommended that processes be strengthened to ensure that aftercare needs are identified and included in discharge planning and discharge instructions.
Closure Date:
11 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services or supplies within the ordered/expected timeframe.
Closure Date:
12 We recommended that processes be strengthened to ensure that patients' and/or caregivers' knowledge and learning abilities are assessed during the inpatient stay.
Closure Date:
13 We recommended that nursing managers monitor the recently implemented staffing methodology.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon discharge and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date PU acquired for all patients with PUs and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
17 We recommended that processes be strengthened to ensure that staff consistently notify the wound care team when an admitted patient has a skin risk of 14 or below.
Closure Date:
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| 13-04241-78 | Combined Assessment Program Review of the Boise VA Medical Center, Boise, Idaho | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure 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 the Surgical Invasive Procedure Committee includes the COS as a member, monitors surgery performance improvement activities, and documents its review of surgical deaths.
Closure Date:
3 We recommended that processes be strengthened to ensure that the review of EHR quality includes most services.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that discharge instructions are consistent with patients¿ identified post-discharge needs and include all elements required by VHA policy and that compliance be monitored.
Closure Date:
6 We recommended that the facility have a Veterans Health Education Coordinator and an active Veterans Health Education Committee.
Closure Date:
7 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
8 We recommended that all members of the facility expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
9 We recommended that processes be strengthened to ensure that SCC minutes include analysis of pressure ulcer data and that the SCC routinely reports program data to facility executive leadership.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location and stage for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
12 We recommended that the facility establish ongoing staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents¿ care plans or document reasons for discontinuing or not providing restorative nursing services and that compliance be monitored.
Closure Date:
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| 13-01488-86 | Administrative Investigation, Failure to Properly Supervise, Misuse of Official Time and Resources, and Prohibited Personnel Practice, VA Center for Innovation, VA Central Office | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff ensure that VBA conducts a review of all RVSRs to ensure that any not performing the functions of their position are either properly detailed or returned to their RVSR duties.
Closure Date:
2 We recommend that the VA Chief of Staff confer with the Office of Human Resources and Administration (OHRA) and the Office of General Counsel (OGC) to determine the appropriate administrative action, if any, to take against Mr. Bramlage.
Closure Date:
3 We recommend that the VA Chief of Staff confer with the OHRA and OGC to determine the appropriate administrative action, if any, to take against Ms. Yeary.
Closure Date:
4 We recommend that the VA Chief of Staff confer with the OHRA and OGC to determine the appropriate administrative action, if any, to take against Ms. Mullins.
Closure Date:
5 We recommend that the VA Chief of Staff ensure that Mr. Bramlage, Ms. Yeary, and Ms. Mullins receive appropriate refresher training in supervisory responsibilities for official travel, performance standards, and appraisals.
Closure Date:
6 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Moore.
Closure Date:
7 We recommend that the VA Chief of Staff ensure that Mr. Moore is issued a bill of collection for $30,990.29 to reimburse VA for a misuse of travel funds.
Closure Date:
8 We recommend that the VA Chief of Staff ensure that Mr. Moore's time and attendance between March and October 2012 is corrected and that he is charged the appropriate annual and sick leave for that time.
Closure Date:
9 We recommend that the VA Chief of Staff ensure that the total amount paid to Mr. Moore for the 20 instances that he was absent without authorization be determined and that Mr. Moore is issued a bill of collection for that amount, since he cannot receive pay for the time that he was absent without authorization.
Closure Date:
10 We recommend that the VA Chief of Staff ensure that the Information Security Officer with oversight for Mr. Moore's VA-issued equipment, to include his laptop and cellular telephone, examine that equipment to remove any unauthorized software and/or content.
Closure Date:
11 We recommend that the VA Chief of Staff ensure that all VACI employees, to include any detailed or assigned to VACI from other organizations, receive refresher training on Federal travel regulations and VA travel policy.
Closure Date:
12 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take concerning the prohibited personnel practice and Mr. Moore's promotion.
Closure Date:
13 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Holly.
Closure Date:
14 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Buchanan.
Closure Date:
15 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Thompson.
Closure Date:
16 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Carroll.
Closure Date:
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| 12-02910-80 | Audit of VA's Hearing Aid Services | Audit | ||
1 We recommend the Under Secretary for Health develop a plan to implement productivity standards and staffing levels for audiology clinics.
Closure Date:
2 We recommend the Principal Executive Director of Office of Acquisition, Logistics, and Construction determine the appropriate staffing levels based on workload at the Denver Acquisition and Logistics Center's repair lab to help meet the timeliness standard for repair.
Closure Date:
3 We recommend the Principle Executive Director of Office of Acquisition, Logistics, and Construction ensure Denver Acquisition and Logistics Center management establish controls to timely track and monitor hearing aids from the date received for repair.
Closure Date:
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| 13-03648-75 | Combined Assessment Program Review of the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that members from Anesthesia and Surgery Services consistently attend Transfusion Review Committee meetings and that attendance records be available to support membership and attendance.
Closure Date:
2 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
5 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 and resident transfers.
Closure Date:
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| 13-03747-76 | Healthcare Inspection – Environment of Care Deficiencies in the Operating Room, VA Connecticut Healthcare System, West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director strengthen policies and procedures related to the operating room environment of care to be consistent with recognized industry standards.
2 We recommended that the Facility Director develop and implement policies and procedures to address management of infectious patients in the operating room; Heating, Ventilation, and Air Conditioning system preventive maintenance; and insect control in the operating room.
3 We recommended that the Facility Director reassess Environmental Management Services staffing needs in the operating room and assign personnel requisite to the workload on each shift.
4 We recommended that the Facility Director ensure that Environmental Management Services staff and supervisors receive training on operating room environment of care requirements, especially terminal cleaning.
5 We recommended that the Facility Director implement procedures to monitor the operating room environment of care and to address identified deficiencies.
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| 13-03626-73 | Combined Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the PRC consistently submit quarterly summary reports to the Clinical Management Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that soiled utility rooms are secured and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that construction sites are secured when unattended and that compliance be monitored.
Closure Date:
4 We recommended that canteen/cafeteria employees be educated on hand hygiene requirements and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training.
Closure Date:
6 We recommended that processes be strengthened to ensure that automated external defibrillator checks are conducted daily and documented and that compliance be monitored.
Closure Date:
7 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:
8 We recommended that the facility establish an interprofessional pressure ulcer committee.
Closure Date:
9 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
10 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 and resident transfers.
Closure Date:
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| 13-04331-63 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Boise VA Medical Center, Boise, Idaho | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that CBOC/PCC staff provide education and counseling for patients with a positive alcohol screen and drinking levels above NIAAA limits.
Closure Date:
3 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
5 We recommended that CBOC/PCC RN Care Managers receive MI interviewing and health coaching training within 12 months of appointment to PACT.
Closure Date:
6 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:
7 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
8 We recommended that staff document the evaluation of each patient’s level of understanding for the medication education.
Closure Date:
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| 13-03178-70 | Healthcare Inspection – Alleged Lapses in Communication and Poor Quality of Care, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that a process is in place to assure that patient information is shared with patients, families, and significant others in an appropriate manner that protects patient privacy.
Closure Date:
2 We recommended that the Facility Director ensure that processes be strengthened for inventory, documentation, storage, and retrieval of patient belongings, and that compliance is monitored.
Closure Date:
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| 13-03624-58 | Healthcare Inspection – Alleged Patient Safety Concerns in the Operating Room, VA Maine Healthcare System, Augusta, Maine | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop and implement a master staffing plan for the operating room based on Association of Perioperative Registered Nurses recommendations to ensure adequate coverage and support for operating room staff.
Closure Date:
2 We recommended that the Facility Director ensure that the Surgical Work Group and Operating Room Committee are implemented and functioning in accordance with Veterans Health Administration and local policies.
Closure Date:
3 We recommended that the Facility Director implement the recommendations made during a protected Veterans Health Administration Surgical Program review.
Closure Date:
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11259