Recommendations
782
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03850-112 | Community Based Outpatient Clinic Reviews at Charles George VA Medical Center, Asheville, NC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
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| 12-03852-110 | Community Based Outpatient Clinic Reviews at Alaska VA Healthcare System, Anchorage, AK | 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 tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that fire and life safety inspections are conducted annually at the Kenai and Mat-Su CBOCs.
Closure Date:
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| 12-03850-106 | Community Based Outpatient Clinic Reviews at Salem VA Medical Center, Salem, VA | Comprehensive Healthcare Inspection Program | ||
| 12-01556-108 | Healthcare Inspection – Alleged Quality of Care Issues and Communication Lapses, Washington DC VA Medical Center, Washington, DC | Hotline Healthcare Inspection | ||
1 We recommended that the Medical Center Director consult with Regional Counsel regarding possible institutional disclosure to the patient's family for whom quality of care concerns were identified.
Closure Date:
2 We recommended that the Medical Center Director take action to improve oversight of PA practice activities in the urology clinic.
Closure Date:
3 We recommended that the Medical Center Director conduct a peer review of the care identified in this report.
Closure Date:
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| 12-04605-107 | Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure that actions implemented to address high-risk areas are documented in Infection Control Committee minutes.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened.
Closure Date:
6 We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education be documented.
Closure Date:
7 We recommended that unit 4C North's expert panel and CLC unit First Floor's expert panel reassess the inpatient staffing needed following the required processes.
Closure Date:
8 We recommended that the annual staffing plan reassessment process ensure that the facility expert panel includes all required members.
Closure Date:
9 We recommended that managers initiate a protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
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| 12-02223-98 | Audit of NCA's Internal Gravesite Review of Headstone and Marker Placement | Audit | ||
| 11-00336-292 | Audit of VHA's Beneficiary Travel Program | Audit | ||
1 We recommend the Under Secretary for Health develop mechanisms to ensure that approved Beneficiary Travel Program reimbursement data are reconciled with payment data.
Closure Date:
2 We recommend the Under Secretary for Health implement training necessary to ensure the Veterans Health Administration staff properly code Beneficiary Travel Program expenses entered into the Financial Management System.
Closure Date:
3 We recommend the Under Secretary for Health establish procedures to mitigate the risk of making duplicate payments on approved travel reimbursements.
Closure Date:
4 We recommend the Under Secretary for Health implement procedures to verify the accuracy of beneficiary addresses at the time of request for beneficiary travel.
Closure Date:
| ||||
| 12-03850-105 | Community Based Outpatient Clinic Reviews at Durham VA Medical Center, Durham, NC | 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 document all required pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
| ||||
| 11-04376-81 | Review of VBA’s Transition to a Paperless Claims Processing Environment | Audit | ||
1 We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology broaden the types of claims tested at additional sites to provide assurance that the range of VBA functionality and processing requirements can be met through VBMS.
Closure Date:
2 We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology establish a plan with milestones to resolve the system issues to ensure system testing does not adversely impact and add to the existing claims processing backlog.
Closure Date:
3 We recommend the Under Secretary for Benefits ensure development of a detailed plan, including costs associated with the long-term scanning solution, so that transformation efforts do not adversely impact and add to the existing claims processing backlog.
Closure Date:
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| 12-03745-93 | Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa | Comprehensive Healthcare Inspection Program | ||
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