Recommendations
572
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00278-164 | Combined Assessment Program Review of the Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired LIPs are consistently initiated and that results are consistently reported to the PSB.
Closure Date:
2 We recommended that the scanning quality control process includes all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
5 We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes.
Closure Date:
6 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect sufficient discussion of findings, action plans, and tracking of items to closure.
Closure Date:
7 We recommended that managers initiate actions to address the 12 identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
8 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
9 We recommended that a process be established to track HPC consults that are not acted upon within the requested timeframe.
Closure Date:
10 We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed and results documented in EHRs and that compliance be monitored.
Closure Date:
11 We recommended that managers initiate protected peer review for the three identified patients and complete any recommended review actions.
Closure Date:
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| 11-00331-160 | Audit of the Community Nursing Home Program | Audit | ||
1 We recommended the Under Secretary for Health ensure Veterans Health Administration community nursing home policies are updated and reissued.
Closure Date:
2 We recommended the Under Secretary for Health conduct a comprehensive national review of nursing homes to ensure veterans are not placed in any nursing homes deemed ineligible by Veterans Health Administration policy, and take appropriate remedial action where necessary.
Closure Date:
3 We recommended the Under Secretary for Health implement a formal oversight and communication process to ensure healthcare facilities comply with Veterans Health Administration nursing home policy and perform proper eligibility reviews.
Closure Date:
4 We recommended the Under Secretary for Health establish a monitoring mechanism to ensure the Office of Geriatrics and Extended Care Strategic Healthcare Group, and healthcare facilities, use the Community Nursing Home Certification Report to monitor the nursing home program and identify high-risk nursing homes.
Closure Date:
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| 13-00026-157 | Community Based Outpatient Clinic Reviews at VA Palo Alto Health Care System, Palo Alto, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that testing of the panic alarm system is documented at the Monterey CBOC.
Closure Date:
4 We recommended that patients' PII are secured and protected at the Monterey CBOC.
Closure Date:
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| 13-00279-156 | Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California | Comprehensive Healthcare Inspection Program | ||
| 12-02503-151 | Administrative Investigation, Misuse of Official Time and Resources and Failure to Properly Supervise, Office of Human Resources and Administration, Washington, DC | Administrative Investigation | ||
| 12-01841-152 | Administrative Investigation, Improper Locality Pay, Service Area Office West and Desert Pacific Healthcare Network, Long Beach, CA | Administrative Investigation | ||
1 We recommend that the SAO West Director ensure that the
employee's personnel records accurately reflect her duty station as San Diego from January [redacted], 2012, to present and that a bill of collection is issued to her for the total amount of improper locality pay given to her.
Closure Date:
2 We recommend that the SAO West Director determine whether the
employee should be permitted to telework, and if so, ensure that Mr. Blanchard and the employee receive annual telework training and complete the proper telework paperwork prior to the employee engaging in any telework.
Closure Date:
3 We recommend that the Director of the Desert Pacific Healthcare Network ensure that [redacted] receives HR training as it relates to duty stations, locality pay, and teleworking.
Closure Date:
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| 11-02487-158 | Healthcare Inspection - Evaluation of Cataract Surgeries and Outcomes in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.
Closure Date:
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| 12-03629-139 | Inspection of VA Regional Office Nashville, Tennessee | Review | ||
| 13-00275-149 | Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
Closure Date:
2 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
Closure Date:
4 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
5 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 for Inpatient Evaluation Center data, utilization management, outcomes from resuscitation, copy and paste, and blood/transfusion reviews.
Closure Date:
6 We recommended that processes be strengthened to ensure that two transfers of CS from one storage area to another are validated and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that inspectors sign and initial inspection documents in accordance with local policy.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated 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 the CLC-based hospice program offers bereavement services to patients and families.
Closure Date:
11 We recommended that processes be strengthened to ensure that interdisciplinary care plans for HPC inpatients include all elements required by local policy.
Closure Date:
12 We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
Closure Date:
13 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:
14 We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
Closure Date:
15 We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
Closure Date:
16 We recommended that managers initiate internal protected peer review for the three identified patients and complete any recommended review actions.
Closure Date:
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| 13-00273-147 | Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Clinical Safety Committee reviews each code episode and that code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the code.
Closure Date:
2 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
3 We recommended that facility managers develop and implement a policy that details quality control for scanning into EHRs.
Closure Date:
4 We recommended that the Transfusion Review Committee meets quarterly and that processes be strengthened to ensure that the blood usage review process includes consistent reporting of data and the results of proficiency testing and peer reviews.
Closure Date:
5 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 for outcomes from resuscitation, EHR reviews, blood/transfusion reviews, and system redesign.
Closure Date:
6 We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Clinical Safety Committee minutes document those actions.
Closure Date:
7 We recommended that facility managers develop and implement a policy that details cleaning of equipment between patients and that compliance with the policy be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that identified women's health-related deficiencies are tracked to closure.
Closure Date:
9 We recommended that the facility implement a PCCT that complies with VHA requirements.
Closure Date:
10 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
11 We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
Closure Date:
12 We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
Closure Date:
13 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:
14 We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education is documented.
Closure Date:
15 We recommended that processes be strengthened to ensure that all new home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order.
Closure Date:
16 We recommended that processes be strengthened to ensure that the home oxygen vendor is notified when a patient is identified by the facility as being a high-risk smoker.
Closure Date:
17 We recommended that nursing managers implement all the required processes for the staffing methodology for nursing personnel.
Closure Date:
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11259