Recommendations
572
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-04604-127 | Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Medical Emergency Committee collects data that measures performance in responding to resuscitation events and that code reviews include screening for clinical issues prior to codes that may have contributed to the occurrence of the codes.
Closure Date:
2 We recommended that the quality control policy for scanning includes the linking of scanned documents to the correct EHR and that processes be strengthened to ensure that the review of EHR quality includes all services and that EHR quality review reports are analyzed.
Closure Date:
3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicate problems or opportunities for improvement are evaluated for effectiveness in Geriatric and Extended Care Performance Improvement Council data and the Patient Flow Coordination Collaborative.
Closure Date:
4 We recommended that facility managers correct the identified cleanliness and environmental safety issues and that the EOC Committee documents progress in EOC Committee minutes.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and discarded when expired.
Closure Date:
6 We recommended that managers initiate actions to address the identified physical security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
7 We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is reconciled and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
Closure Date:
9 We recommended that the CS Coordinator's duties be included in his or her position description.
Closure Date:
10 We recommended that processes be strengthened to ensure that all CS inspectors are appointed in writing by the facility Director prior to assuming their duties.
Closure Date:
11 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates.
Closure Date:
12 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS include all required elements and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated physician and administrative support person.
Closure Date:
14 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
15 We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the Computerized Patient Record System.
Closure Date:
16 We recommended that processes be strengthened to ensure that patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensures that all required staff are members of the unit-based and facility expert panels.
Closure Date:
18 We recommended that members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
19 We recommended that the facility complete the staffing methodology process.
Closure Date:
20 We recommended that the facility establish a construction safety program with a multidisciplinary committee that effectively monitors infection control, safety, and security issues during construction and renovation activities in accordance with VHA requirements.
Closure Date:
21 We recommended that all identified infection control, safety, and security deficiencies for the Building 7 construction project be corrected and that compliance be monitored. VA
Closure Date:
| ||||
| 12-03077-122 | Combined Assessment Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
| 12-04191-123 | Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that
results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that
continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure that
code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the code.
Closure Date:
4 We recommended that processes be strengthened to ensure that
the review of EHR quality includes all services.
Closure Date:
5 We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
6 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
Closure Date:
7 We recommended that processes be strengthened to ensure IC Committee minutes reflect follow-up on actions that were implemented to address identified problems.
Closure Date:
8 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
Closure Date:
9 We recommended that processes be strengthened to ensure that KT clinic staff consistently change linens and clean equipment between patient use.
Closure Date:
10 We recommended that the stained privacy curtains in the KT clinic be replaced and that privacy curtains be routinely inspected and replaced as needed.
Closure Date:
11 We recommended that processes be strengthened to ensure that medications in the PT clinic are secured at all times.
Closure Date:
12 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
13 We recommended that processes be strengthened to ensure
that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
Closure Date:
14 We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
15 We recommended that the facility expert panel review unit 34's and CLC unit 3's expert panels' recommendations.
Closure Date:
16 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:
17 We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
Closure Date:
18 We recommended that processes be strengthened to ensure that IC staff conduct contractor TB risk assessments prior to construction project initiation.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor TB skin test results are documented.
Closure Date:
20 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
Closure Date:
21 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
| ||||
| 12-03854-115 | Community Based Outpatient Clinic Reviews at William S. Middleton Memorial Veterans Hospital, Madison, WI | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
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| 12-03753-121 | Healthcare Inspection – Issues at a VA Mid South Healthcare Network Dental Clinic | Hotline Healthcare Inspection | ||
1 We recommend that the System Director ensure that dental clinic staff have adequate knowledge regarding periodontal disease.
Closure Date:
2 We recommend that the System Director ensure treatment plans are developed, revised, followed, and documented.
Closure Date:
3 We recommend that the System Director develop and implement a plan to improve communication and professional interaction among dental clinic staff.
Closure Date:
| ||||
| 12-03851-117 | Community Based Outpatient Clinic Reviews at Marion VA Medical Center, Marion, IL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the parent Facility Director ensures that each CBOC is assigned a WH Liaison and that the WH Liaison collaborates with the Women Veterans Program Manager.
Closure Date:
2 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
3 We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the service chiefs' documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Farmington and West Plains CBOCs.
Closure Date:
6 We recommended that the PSB grants LIPs setting-specific privileges that are consistent with the services provided at the Farmington and West Plains CBOCs.
Closure Date:
7 We recommended that signage is installed at the West Plains CBOC to clearly identify the location of fire extinguishers.
Closure Date:
8 We recommended that fire safety inspections are conducted annually at the West Plains CBOC.
Closure Date:
9 We recommended that processes are strengthened to ensure patient privacy is maintained during examination at the Farmington CBOC.
Closure Date:
10 We recommended that managers ensure that AEDs are checked daily at the West Plains CBOC, as required by facility policy.
Closure Date:
| ||||
| 12-03477-118 | Inspection of Veterans Service Center Cheyenne, Wyoming | Review | ||
| 12-03851-102 | Community Based Outpatient Clinic Reviews at John J. Pershing VA Medical Center, Poplar Bluff, MO | Comprehensive Healthcare Inspection Program | ||
| 12-03854-114 | Community Based Outpatient Clinic Reviews at Iowa City VA Health Care System, Iowa City, IA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that the FPPE review for the Cedar Rapids CBOC providers is included in the Clinical Executive Board meeting minutes.
Closure Date:
| ||||
| 12-03852-109 | Community Based Outpatient Clinic Reviews at Spokane VA Medical Center, Spokane, WA | Comprehensive Healthcare Inspection Program | ||
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