Recommendations
782
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03853-172 | Community Based Outpatient Clinic Reviews at Battle Creek VA Medical Center, Battle Creek, MI, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL | Comprehensive Healthcare Inspection Program | ||
| 12-02955-178 | Healthcare Inspection – Patient Care Issues and Contract Mental Health Program Mismanagement, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health take note and rectify the deficiencies described in this report with respect to the provision of quality mental health care and contract management, with the goal that veterans receive the highest quality medical care from either the VA or its partners.
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2 We recommended that the Facility Director evaluate the care of patients discussed in this report with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patients.
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| 12-03869-179 | Healthcare Inspection - Mismanagement of Inpatient Mental Health Care, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health develops national policies that address contraband, visitation, urine drug screens, and escort services for inpatient mental health units.
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2 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit develops and implements policies that adequately address contraband, visitation, urine drug screening, and escort service.
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3 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit employs safeguards for documentation that accurately reflect staff observation of patients.
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4 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit strengthens program oversight including follow-up actions taken by leadership in response to patient incidents.
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5 We recommended that the VISN and Facility Directors ensure that the facility strengthen and improve the RCA process to ensure that all information and documentation related to the event are reviewed and that follow up actions are completed and timely.
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6 We recommended that the VISN and Facility Directors ensure that the facility improves communication with staff regarding debriefings and planned actions to address identified deficiencies.
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7 We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health units are equipped with functional and well-maintained life support equipment.
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8 We recommended that the VISN and Facility Directors ensure that the facility evaluates the care of the subject patient with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patient.
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| 12-04524-171 | -Interim Report - Participation in VBA's Veterans Retraining Assistance Program | Audit | ||
| 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.
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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.
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3 We recommended that processes be strengthened to ensure that the Code Committee reviews each code episode.
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4 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed.
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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.
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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.
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7 We recommended that the PCCT includes a dedicated psychologist and administrative support person.
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8 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
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9 We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the CPRS.
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10 We recommended that processes be strengthened to ensure that the Chief of Staff reviews HRCP activities at least quarterly.
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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.
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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.
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2 We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
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3 We recommended that processes be strengthened to ensure that exit signs identifying alternate routes for egress are posted within construction sites.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
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3 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
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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.
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5 We recommended that managers ensure that staff are trained and knowledgeable of the local CBOC medical and MH emergency policy.
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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.
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2 We recommend the Philadelphia VA Regional Office Director provide refresher training to ensure staff establish suspense diaries for temporary 100 percent.
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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.
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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.
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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.
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11259