Recommendations
782
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00026-197 | Community Based Outpatient Clinic Reviews at VA Maine Healthcare System, Augusta, ME | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process be established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted timeframe and that notification is documented in the EHR.
Closure Date:
2 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:
3 We recommended that patients' PII is protected and secured at the Bangor CBOC.
Closure Date:
4 We recommended that the Chief of OI&T evaluates security of the IT closet and implements required measures at the Bangor CBOC.
Closure Date:
5 We recommended that all identified EOC deficiencies and corrective actions at the Bangor and Calais CBOCs are tracked and trended by the EOC Committee.
Closure Date:
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| 13-00026-196 | Community Based Outpatient Clinic Reviews at Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted timeframe and that notification is documented in the EHR.
Closure Date:
2 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:
3 We recommended that the Acting Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
Closure Date:
4 We recommended that laboratory specimens are secured during transport from the CBOCs to the parent facility to prevent the disclosure of patients' PII.
Closure Date:
5 We recommended that all identified EOC deficiencies and corrective actions be tracked and trended by the EOC Committee.
Closure Date:
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| 13-00940-193 | Healthcare Inspection – Alleged Delays in Notifying Patients of Biopsy Results, W.G. (Bill) Hefner VA Medical Center, Salisbury, NC | Hotline Healthcare Inspection | ||
| 13-01320-200 | Healthcare Inspection – Inappropriate Use of Insulin Pens, VA Western New York Healthcare System, Buffalo, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health finalize VHA's Clinical Operations Guideline for 'Implementation of a Large Scale Disclosure Decision' to include a monitoring process that reflects the urgency of disclosing adverse events to patients.
Closure Date:
2 We recommended that the VISN Director review the facts that led to the misuse of insulin pens and take appropriate administrative action.
Closure Date:
3 We recommended that the Facility Director implement a process to ensure the facility's Medication Use, Nursing Practice, and Commodity Standards Committees and other relevant leadership evaluate the risks and benefits before introducing new medical products or supplies that require changes in nursing procedures.
Closure Date:
4 We recommended that the Facility Director strengthen nurse education practices when introducing new medical products or supplies and ensure that all nurses are made aware of how to find and use the facility's nursing practice procedures.
Closure Date:
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| 13-00893-195 | Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates or refresher training.
Closure Date:
3 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
Closure Date:
4 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:
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| 13-00026-191 | Community Based Outpatient Clinic Reviews at Cheyenne VA Medical Center, Cheyenne, WY | Comprehensive Healthcare Inspection Program | ||
| 13-00026-190 | Community Based Outpatient Clinic Reviews at VA New Jersey Health Care System, East Orange, NJ | 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 tetanus vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the MSEC grants privileges that are consistent with the services provided at the Paterson and Piscataway CBOCs.
Closure Date:
6 We recommended that managers ensure that signage is installed to direct patient to handicapped parking and accessible entrance at the Paterson CBOC.
Closure Date:
7 We recommended that the Chief of OI&T implements, maintains, and reviews IT closet access logs at the Piscataway CBOC.
Closure Date:
8 We recommended that biohazardous waste containers at the Piscataway CBOC are stored appropriately.
Closure Date:
9 We recommended that managers ensure that Paterson and Piscataway CBOC staff are trained and knowledgeable of the CBOC’s MH emergency policy.
Closure Date:
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| 12-03746-161 | Combined Assessment Program Review of the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPE for newly hired licensed independent practitioners are consistently initiated.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
Closure Date:
4 We recommended that the Consolidation Building have fire extinguisher signage in place in accordance with National Fire Protection Association standards.
Closure Date:
5 We recommended that processes be strengthened to ensure that post-operative patients are transported using clean elevators.
Closure Date:
6 We recommended that processes be strengthened to ensure that non-HPC staff receive end-of-life training.
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 all Home Oxygen Plan of Care notes have a physician co-signature.
Closure Date:
9 We recommended that the construction and renovation activities multidisciplinary committee continues to meet.
Closure Date:
10 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
11 We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results are documented.
Closure Date:
12 We recommended that processes be strengthened to ensure that construction site inspection documentation includes all the required elements.
Closure Date:
13 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are documented in Infection Control Committee minutes.
Closure Date:
14 We recommended that processes be strengthened to ensure that designated employees receive initial and ongoing construction safety training and that compliance be monitored.
Closure Date:
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| 13-01743-192 | Combined Assessment Program Summary Report – Evaluation of Moderate Sedation in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.
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| 13-00026-189 | Community Based Outpatient Clinic Reviews at Northport VA Medical Center, Northport, NY | 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 tetanus vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that access is improved for disabled veterans.
Closure Date:
6 We recommended that staff are trained in accessing MSDS for hazardous chemicals in the clinical area.
Closure Date:
7 We recommended that computer screens are secured to eliminate viewing of PII by unauthorized individuals.
Closure Date:
8 We recommended that laboratory specimens are secured during transport from the CBOC to the parent facility.
Closure Date:
9 We recommended that the server closet is maintained according to IT safety and security standards.
Closure Date:
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11259