Recommendations
638
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00374-174 | Combined Assessment Program Review of the Manchester VA Medical Center, Manchester, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the Professional Standards Board.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Code Committee reviews each code episode.
Closure Date:
4 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed.
Closure Date:
5 We recommended that managers initiate actions to address the one identified physical security deficiency and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
6 We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
Closure Date:
7 We recommended that the PCCT includes a dedicated psychologist and administrative support person.
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 processes be strengthened to ensure that HPC consult responses are attached to the consult request in the CPRS.
Closure Date:
10 We recommended that processes be strengthened to ensure that the Chief of Staff reviews HRCP activities at least quarterly.
Closure Date:
11 We recommended that processes be strengthened to ensure that construction safety and infection surveillance activities related to construction projects are initiated at the same time as the projects and documented in the minutes of each committee.
Closure Date:
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| 13-00431-173 | Combined Assessment Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that CS inspectors consistently perform and document reconciliation of 1 day's dispensing from the pharmacy to each automated unit and that compliance be monitored.
Closure Date:
2 We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
Closure Date:
3 We recommended that processes be strengthened to ensure that exit signs identifying alternate routes for egress are posted within construction sites.
Closure Date:
4 We recommended that processes be strengthened to ensure that sprinkler head paint protectors are removed as soon as possible and that in the event the protectors remain on in unattended areas for longer than 4 hours in a 24-hour period, a fire watch be implemented.
Closure Date:
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| 12-04179-167 | Inspection of VA Regional Office Baltimore, Maryland | Review | ||
1 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure staff review all existing reminder notifications and schedule medical reexaminations as required.
Closure Date:
2 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure that for the future, staff routinely review reminder notifications and timely schedule medical reexaminations as required.
Closure Date:
3 We recommended the Baltimore VA Regional Office Director conduct a review of the 478 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
4 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure compliance with the Veterans Benefits Administration’s second signature requirements for traumatic brain injury claims.
Closure Date:
5 We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure staff timely address all required elements of Systematic Analyses of Operations.
Closure Date:
6 We recommended the Baltimore VA Regional Office Director develop and implement a plan outlining how Veterans Service Center staff will accomplish all required homeless veterans outreach services, including creating a resource directory and regularly contacting homeless shelters and service providers.
Closure Date:
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| 12-03939-175 | Healthcare Inspection - Alleged Inappropriate Surveillance James A. Haley Veterans’ Hospital Tampa, Florida | Hotline Healthcare Inspection | ||
| 13-00026-166 | Community Based Outpatient Clinic Reviews at Dayton VA Medical Center, Dayton, OH | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal 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 managers ensure that the facility policy for semi-annual EOC rounds includes the CBOCs and that EOC meeting minutes reflect sufficient discussion of CBOCs' issues, deficiencies, and items.
Closure Date:
5 We recommended that managers ensure that staff are trained and knowledgeable of the local CBOC medical and MH emergency policy.
Closure Date:
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| 12-03475-169 | Inspection VA Regional Office Philadelphia, Pennsylvania | Review | ||
1 We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration policy regarding timely benefits reduction actions.
Closure Date:
2 We recommend the Philadelphia VA Regional Office Director provide refresher training to ensure staff establish suspense diaries for temporary 100 percent.
Closure Date:
3 We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims.
Closure Date:
4 We recommend the Philadelphia VA Regional Director develop and implement a plan to ensure staff compliance with Veterans Benefits Administration second signature requirements for processing traumatic brain injury claims.
Closure Date:
5 We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly provide outreach to homeless shelters and service providers.
Closure Date:
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| 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 | ||
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