Recommendations
572
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-02476-103 | Healthcare Inspection – Mid-Level Provider Oversight, George E. Wahlen VA Medical Center, Salt Lake City, UT | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director establish an equivalent process to Focused Professional Practice Evaluations and Ongoing Professional Practice Evaluations for mid-level scope of practice reviews.
Closure Date:
2 We recommended that the facility Director ensure that the mid-level Professional Standards Board forwards their recommendations for the granting of scopes of practice to the Medical Executive Committee for review.
Closure Date:
3 We recommended that all staff in the Intensive Care Unit, including the attending physicians, receive training on adverse event reporting.
Closure Date:
4 We recommended that systems be strengthened to ensure that all Intensive Care Unit near misses and adverse events are reported.
Closure Date:
| ||||
| 12-04192-97 | Combined Assessment Program Review of the San Francisco VA Medical Center, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
| 12-04108-96 | Healthcare Inspection–Appointment Scheduling and Access Patient Call Center, VA San Diego Healthcare System, San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensures that Patient Call Center agents follow policy and procedures for scheduling follow-up appointments and managing non-urgent symptomatic calls.
Closure Date:
2 We recommended that the System Director ensures that timeframes for the primary care teams to follow-up with patients be established.
Closure Date:
| ||||
| 12-04189-95 | Combined Assessment Program Review of the Oklahoma City VA Medical Center,Oklahoma City, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers initiate actions to address the three identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
2 We recommended that processes be strengthened to ensure that monthly inspections of automatic dispensing machines are conducted in accordance with local policy.
Closure Date:
3 We recommended that processes be strengthened to ensure that monthly CS inspection findings summaries and quarterly trend reports are consistently provided to the facility Director.
Closure Date:
4 We recommended that the CS Coordinator's duties be included in the position description.
Closure Date:
5 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy areas with CS are conducted and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
8 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:
9 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
| ||||
| 12-04190-89 | Combined Assessment Program Review of the North Florida/South Georgia Veterans Health System, Gainesville, Florida | 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 that results are reported to the Medical Executive Committee.
Closure Date:
2 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
4 We recommended that processes be strengthened to ensure that staff perform continuing stay reviews for at least 75 percent of acute care patients.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Emergency Effectiveness Committee reviews individual resuscitation events.
Closure Date:
6 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
7 We recommended that processes be strengthened to ensure that the blood usage review process includes the results of proficiency testing done by the laboratory.
Closure Date:
8 We recommended processes be strengthened to ensure that the PCCT includes a dedicated nurse and administrative support person.
Closure Date:
9 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
10 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
11 We recommended that processes be strengthened to ensure that all designated staff complete respirator fit testing.
Closure Date:
| ||||
| 12-00710-85 | Combined Assessment Program Review of the VA New York Harbor Healthcare System,New York, New York | Comprehensive Healthcare Inspection Program | ||
| 11-00711-74 | Healthcare Inspection – Foot Care for Patients with Diabetes and Additional Risk Factors for Amputation | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.
Closure Date:
| ||||
| 12-03355-88 | Inspection of the VA Regional Office, Detroit, Michigan | Review | ||
| 11-04359-80 | Review of VHA's South Texas Veterans Health Care System's Management of Fee Care Funds | Audit | ||
1 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for clinical and fee staff to properly process authorizations for fee care.
Closure Date:
2 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for fee staff to process payments of vendor invoices timely.
Closure Date:
3 We recommended the Director of the South Texas Veterans Health Care System ensure clinical and fee staff receive periodic training on fee care procedures.
Closure Date:
4 We recommended the Director of the South Texas Veterans Health Care System establish independent oversight mechanisms, such as periodic audits or reviews by the Compliance Officer, to ensure that newly established procedures at the South Texas Veterans Health Care System are followed to properly control and manage funds for its fee care program.
Closure Date:
5 We recommended the Director of the Veterans Integrated Service Network establish independent oversight mechanisms, such as periodic audits or reviews, to ensure that procedures for properly controlling and managing fee care program funds are followed at the South Texas Veterans Health Care System.
Closure Date:
| ||||
| 12-04214-83 | Healthcare Inspection – Emergency Department Evaluation of a Homeless Veteran VA North Texas Health Care System, Dallas, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the facility develops a written SOP for emergency department patient flow and orientation is provided to all emergency department staff and on-call personnel.
Closure Date:
2 We recommended that the Facility Director ensure that EDIS is used as required.
Closure Date:
3 We recommended that the Facility Director ensure that SW services are provided in the emergency department as required.
Closure Date:
| ||||
11259