Recommendations
514
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03858-46 | Healthcare Inspection – Alleged Resident Abuse and Abuse Reporting Irregularities at the Pueblo Community Living Center, VA Eastern Colorado Healthcare System, Denver, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the system Director ensure all Associate Chiefs of Nursing and Community Living Center staff receive retraining on the requirements for reporting allegations of abuse.
Closure Date:
2 We recommended that the system Director ensures procedures to report, log, track, trend, and analyze injuries of unknown origin at the Community Living Center are developed.
Closure Date:
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| 12-02277-49 | Healthcare Inspection - Clinical and Administrative Allegations Involving Surgical Service, Carl Vinson VA Medical Center, Dublin, GA | Hotline Healthcare Inspection | ||
| 12-00581-27 | Community Based Outpatient Clinic Reviews Minden (Carson Valley), NV; Auburn (Sierra Foothills), Chula Vista, and Escondido, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensure that foot screening and patient referral guidelines are established in accordance with VHA policy.
Closure Date:
2 We recommended that the Sierra Foothills CBOC clinicians document foot care education to diabetic patients in CPRS.
Closure Date:
3 We recommended that the Carson Valley CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
Closure Date:
4 We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
5 We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document that therapeutic footwear or orthotics is prescribed to diabetic patients identified at high risk for extremity ulcers and amputation.
Closure Date:
6 We recommended that the Chula Vista and Escondido CBOC clinicians document foot care education to diabetic patients in CPRS.
Closure Date:
7 We recommended that the Chula Vista and Escondido CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
Closure Date:
8 We recommended that the Chula Vista and Escondido CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
9 We recommended that the Carson Valley CBOC establish a process to ensure that patients with normal mammogram results are notified of results within the allotted timeframe and that notification is documented in the medical record.
Closure Date:
10 We recommended that the Women¿s Health Liaison at the Chula Vista CBOC attend the Women¿s Health Committee meetings and routinely collaborate with the Women Veterans Program Manager.
Closure Date:
11 We recommended that the privileges granted to providers are consistent with the services provided at the Chula Vista CBOC and that privileges are setting specific at Chula Vista and Escondido CBOCs.
Closure Date:
12 We recommended that OPPE data be maintained in all providers¿ profiles at the Escondido CBOC.
Closure Date:
13 We recommended that managers collect and analyze data for hand hygiene at the Carson Valley and Sierra Foothills CBOCs.
Closure Date:
14 We recommended that the VISN and Facility Directors ensure that the deficiencies at the Escondido CBOC are addressed and corrected to ensure compliance with the ADA requirements.
Closure Date:
15 We recommended that the Chula Vista CBOC implement a process to ensure that patient PII is protected and secured.
Closure Date:
16 We recommended that the Network Contracting Office, in conjunction with VISN and Facility Directors, award a competitive long-term contract and to ensure that future acquisitions allow for adequate planning time to avoid the need for ICA.
Closure Date:
17 We recommended that the Service Area Office (SAO) West Director and MSO Directors ensure that the use of ICA complies with VA directives.
Closure Date:
18 We recommended that the SAO West Director and Network Contract Manager ensure appropriate oversight and enforcement of VA directives before an ICA is approved and a contract is signed.
Closure Date:
19 We recommended that the SAO West Director and Network Contract Manager ensure that contracting officers are held accountable for noncompliance with VA directives.
Closure Date:
20 We recommended that the Facility Director and Network Contract Manager confer with Regional Counsel to determine the amount and collectability of all overpayments.
Closure Date:
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| 12-01758-40 | Healthcare Inspection – Alleged Clinical and Administrative Issues, VA Loma Linda Healthcare System, Loma Linda, CA | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that MH patients receive timely care, including initial evaluations within 24 hours and comprehensive evaluations within 14 days.
Closure Date:
2 We recommended that the Facility Director establish a MH Executive Council as required by VHA.
Closure Date:
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| 11-03655-30 | Community Based Outpatient Clinic Reviews Brooklyn (Chapel Street) and Sunnyside (Queens), NY; Franklin (Venango), PA | Comprehensive Healthcare Inspection Program | ||
| 12-03074-29 | Combined Assessment Program Review of the VA Northern California Health Care System, Sacramento, California | Comprehensive Healthcare Inspection Program | ||
| 12-02600-28 | Combined Assessment Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
Closure Date:
2 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:
3 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
Closure Date:
4 We recommended that processes be strengthened to ensure that test strips are stored and glucometers are maintained in accordance with the manufacturers¿ recommendations.
Closure Date:
5 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
6 We recommended that processes be strengthened to ensure that staff make and document post-discharge telephone calls in accordance with local policy.
Closure Date:
7 We recommended that the locked acute MH unit have camera surveillance monitoring at all required locations.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PR Committee is consistently notified when corrective actions are completed and that this notification is documented in the meeting minutes.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Medical Records Committee provides oversight and coordination of EHR quality reviews and that EHR quality reviews are consistently completed for all services, including Surgical Service.
Closure Date:
10 We recommended that processes be strengthened to ensure that aggregated data from resuscitation episodes is reported to the CPR Subcommittee monthly and documented in the meeting minutes.
Closure Date:
11 We recommended that all required services be available to polytrauma outpatients and that minimum staffing levels be maintained.
Closure Date:
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| 12-01877-25 | Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
Closure Date:
3 We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that all discharged MH patients receive follow-up within 7 days of discharge and that compliance be monitored.
Closure Date:
6 We recommended that the facility offer MH services at least one evening per week.
Closure Date:
7 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
Closure Date:
9 We recommended that processes be strengthened to ensure that patient care areas and fall mats are clean.
Closure Date:
10 We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
Closure Date:
11 We recommended that processes be strengthened to ensure that sensitive patient information displayed on computer screens is secured.
Closure Date:
12 We recommended that processes be strengthened to ensure that final summary notes for ethics consults pertaining to active clinical cases are documented in the EHRs.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
Closure Date:
14 We recommended that processes be strengthened to ensure that glucometers are cleaned and maintained in accordance with the manufacturer's recommendations.
Closure Date:
15 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Closure Date:
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| 12-02188-15 | Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the holes in the walls be repaired and that processes be strengthened to ensure that patient care areas are clean.
Closure Date:
2 We recommended that the DRRTP have Class K fire extinguishers available in the kitchens used by residents.
Closure Date:
3 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
Closure Date:
4 We recommended that processes be strengthened to ensure that designated employees at the John Cochran dental clinic complete initial laser safety training and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that needle safety devices are available in the Jefferson Barracks dental clinic and that use of the devices be monitored.
Closure Date:
6 We recommended that DRRTP and SA RRTP managers update the policies to safely manage medications and written procedures for contraband detection to include all VHA requirements and that compliance with the updated policies and procedures be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that monthly DRRTP and SA RRTP self-inspections are conducted and that documentation includes all required elements and corrective actions taken when deficiencies are identified.
Closure Date:
8 We recommended that processes be strengthened to ensure that daily SA RRTP resident room inspections are thorough.
Closure Date:
9 We recommended that processes be strengthened to ensure that SA RRTP rooms occupied by female veterans are safe, private, and secure.
Closure Date:
10 We recommended that processes be strengthened to ensure that all non-physician employees complete the facility¿s required training program prior to assisting with or providing moderate sedation.
Closure Date:
11 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that informed consents are completed for all patients undergoing moderate sedation and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
Closure Date:
13 We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
Closure Date:
14 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up at least weekly during the first 30 days after discharge and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that all patients discharged from inpatient MH receive follow-up MH appointments prior to being discharged.
Closure Date:
17 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
Closure Date:
18 We recommended that the annual staffing plan reassessment process ensure that unit 6N's unit-based expert panel includes representatives from all nursing roles.
Closure Date:
19 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
20 We recommended that unit 6N's nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
21 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results have a comprehensive evaluation within the required timeframe.
Closure Date:
22 We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are provided to polytrauma outpatients and/or the patients' families.
Closure Date:
23 We recommended that processes be strengthened to ensure that staff in all testing areas are aware of the location of the current electronic glucose POCT manual.
Closure Date:
24 We recommended that processes be strengthened to ensure that staff complete the action required in response to critical test results and document in the glucometer or EHR the name of the specific provider notified of the critical test results.
Closure Date:
25 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers or required by local policy.
Closure Date:
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| 11-00324-20 | Audit of VA’s Office of Information Technology Strategic Human Capital Management | Audit | ||
1 We recommended that the Assistant Secretary for Information Technology establish a strategic human capital plan development process that includes Office of Information Technology's senior management, managers, and employees along with appropriate stakeholders from across VA and its administrations.
Closure Date:
2 We recommended that the Assistant Secretary for Information Technology develop and implement a strategic human capital plan that includes roles and responsibilities; human capital goals, objectives, and strategies; performance measures; and milestones as outlined in the Human Capital Assessment and Accountability Framework.
Closure Date:
3 We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology's strategic human capital plan is aligned with VA's missions, goals, and objectives; and integrated into the Information Technology and VA Strategic Plans.
Closure Date:
4 We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology has an adequate number of leadership and staff positions assigned to administer its strategic human capital program.
Closure Date:
5 We recommended that the Assistant Secretary for Information Technology develop a leadership succession plan, including key actions and associated milestones for its implementation.
Closure Date:
6 We recommended that the Assistant Secretary for Information Technology ensure that all information technology leadership and employee competency assessments and gap analyses are completed.
Closure Date:
7 We recommended that the Assistant Secretary for Information Technology develop leadership and workforce development and hiring strategies for closing identified competency gaps.
Closure Date:
8 We recommended that the Assistant Secretary for Information Technology maintain a current listing of contracts used by each OIT organizational element and the functions performed to identify areas where OIT uses contractors to address competency gaps.
Closure Date:
9 We recommended that the Assistant Secretary for Information Technology institute metrics and a process to measure the effectiveness of its strategies for evaluating and improving human capital management.
Closure Date:
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11259