Recommendations
617
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03543-73 | Healthcare Inspection – Alleged Patient Safety Deficiencies in the Community Living Center, Canandaigua VA Medical Center, Canandaigua, New York | Hotline Healthcare Inspection | ||
| 12-02352-72 | Healthcare Inspection – Pharmacy and Quality of Care Issues, VA Hudson Valley Health Care System, Castle Point, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Director ensure that the recommendations included in the Administrative Investigation Board report are complied with.
Closure Date:
2 We recommended that the Director ensure that all pharmacy staff be provided ethics training to ensure that employees report unethical behavior without fear of repercussion.
Closure Date:
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| 12-03076-65 | Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
Closure Date:
2 We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
Closure Date:
3 We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
Closure Date:
4 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
Closure Date:
5 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:
6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
7 We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.
Closure Date:
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| 10-01937-63 | Review of Allegations at VA Medical Center, Providence, Rhode Island | Audit | ||
| 12-03346-69 | Review of VHA's Minor Construction Program | Audit | ||
1 We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
Closure Date:
2 We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
Closure Date:
3 We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
Closure Date:
4 We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
Closure Date:
5 We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
Closure Date:
6 We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
Closure Date:
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| 12-03741-61 | Combined Assessment Program Review of the VA Maine Healthcare System,Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
Closure Date:
3 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 by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
Closure Date:
4 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
Closure Date:
5 We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
Closure Date:
6 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
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| 11-00317-37 | Audit of Vocational Rehabilitation and Employment Program's Self-Employment Services at Eastern and Central Area Offices | Audit | ||
1 We recommended the Under Secretary for Benefits implement procedures to improve the accuracy of data in Corporate WINRS.
Closure Date:
2 We recommended the Under Secretary for Benefits perform a data integrity review comparing Corporate WINRS to active self-employment Counseling/Evaluation/Rehabilitation files and take corrective action as needed.
Closure Date:
3 We recommended the Under Secretary for Benefits develop and implement performance measures that evaluate the success of self-employment services.
Closure Date:
4 We recommended the Under Secretary for Benefits provide training to Eastern and Central area Vocational Rehabilitation and Employment staff to ensure they understand the criteria used to determine rehabilitation status for participants in self-employment services.
Closure Date:
5 We recommended the Under Secretary for Benefits include guidance in Veterans Benefits Administration's Manual M28 to clarify when it is appropriate to provide services for veterans with an established business under a self-employment plan.
Closure Date:
6 We recommended the Under Secretary for Benefits revise Veterans Benefits Administration's Manual M28, Part IV, to ensure Veterans Benefits Administration's guidance aligns with Title 38, Code of Federal Regulations, for approval of self-employment plans.
Closure Date:
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| 12-03071-53 | Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
| 12-03075-52 | Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC-Safety and IC Committee minutes reflect sufficient data analysis, actions implemented, and tracking of items to closure.
Closure Date:
2 We recommended that a comprehensive EOC inspection of the ED be conducted and that appropriate actions be taken to correct IC and safety deficiencies.
Closure Date:
3 We recommended that processes be strengthened to ensure that emergency exits are not obstructed.
Closure Date:
4 We recommended that processes be strengthened to ensure that MSDS inventory lists and hazardous materials information binders are current and that staff are trained on accessing the electronic MSDS materials.
Closure Date:
5 We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and SCI outpatient clinic.
Closure Date:
6 We recommended that processes be strengthened to ensure that medications, chemicals, solutions, and cleaning carts are properly secured.
Closure Date:
7 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections and daily room inspections are conducted and that inspection reports contain adequate documentation of follow-up.
Closure Date:
8 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
9 We recommended that processes be strengthened to ensure that all informed consents are completed appropriately and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
Closure Date:
10 We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo monthly urine drug screenings.
Closure Date:
11 We recommended that processes be strengthened to ensure that discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated timely and documented and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that all patients are notified of biopsy results within the required timeframe and that clinicians document notification in the EHR.
Closure Date:
14 We recommended that processes be strengthened to ensure that clinician notification of critical test results is documented on the required template.
15 We recommended that local policies related to FSBG monitoring and patient management be updated to reflect actual practice.
Closure Date:
16 We recommended that processes be strengthened to ensure that all services complete EHR quality reviews.
Closure Date:
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| 12-03073-57 | Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs are initiated for all newly hired licensed independent practitioners.
Closure Date:
2 We recommended that processes be strengthened to ensure that all completed ethics consultations are documented in ECWeb.
Closure Date:
3 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
4 We recommended that processes be strengthened to ensure that patients are appropriately monitored during moderate sedation
Closure Date:
5 We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinical staff in areas where moderate sedation is performed are aware of local policy requirements for identifying correct surgical and invasive procedure sites when the sites cannot be marked.
Closure Date:
7 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers.
Closure Date:
8 We recommended that processes be strengthened to ensure that providers document care hand-off in accordance with local policy.
Closure Date:
9 We recommended that processes be strengthened to ensure that interdisciplinary teams develop treatment plans for all polytrauma outpatients who need them and that the plans contain all required elements.
Closure Date:
10 We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
Closure Date:
11 We recommended that processes be strengthened to ensure that service directors develop program-specific competencies and training for all staff assigned to the Polytrauma-TBI Program.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that SCI outpatient clinic employees receive population-specific training.
Closure Date:
14 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:
15 We recommended that the facility implement the mandated staffing methodology for nursing personnel.
Closure Date:
16 We recommended that processes be strengthened to ensure that all POCT instruments are inspected by biomedical engineering prior to initial use.
Closure Date:
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11259