Recommendations
933
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00026-276 | Community Based Outpatient Clinic Reviews at Coatesville VA Medical Center, Coatesville, PA | 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 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:
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| 13-01972-284 | Combined Assessment Program Review of the Charlie Norwood VA Medical Center, Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
Closure Date:
2 We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to codes that may have contributed to the occurrence of the codes.
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 Infection Prevention/Control Committee minutes reflect follow-up on actions that were implemented to address identified problems.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient care area ventilation system outlets, public restrooms, and nourishment refrigerators are clean and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that restrooms designated for female patients in the women's health clinic have door locks.
Closure Date:
8 We recommended that processes be strengthened to ensure that SPS sterile storage area humidity levels are maintained within acceptable levels and that compliance be monitored.
Closure Date:
9 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:
10 We recommended that processes be strengthened to ensure that inspectors verify five hard copy prescription orders for all non-pharmacy areas and that compliance will be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that equipment used for medication administration is routinely inspected and repaired or removed from service.
Closure Date:
13 We recommended that processes be strengthened to ensure that prescription medications are secured at all times and that compliance be monitored.
Closure Date:
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| 13-00026-285 | Community Based Outpatient Clinic Reviews at Charlie Norwood VA Medical Center, Augusta, GA | 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 tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that the facility ensures fire drills are completed as required at the Aiken and Athens CBOCs.
Closure Date:
5 We recommended that fire extinguisher signage is installed at the Aiken CBOC as required.
Closure Date:
6 We recommended that testing of the panic alarm system is documented at the Aiken CBOC.
Closure Date:
7 We recommended that the facility ensures patient privacy is respected at the Athens CBOC.
Closure Date:
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| 13-00026-290 | Community Based Outpatient Clinic Reviews at Carl Vinson VA Medical Center, Dublin, GA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
2 We recommended that managers conduct chemical inventories and update MSDS lists twice a year at the Brunswick CBOC.
Closure Date:
3 We recommended that the Chief of OI&T implements required security measures at the Macon CBOC.
Closure Date:
4 We recommended that managers document completion of EOC rounds and identify deficiencies in the parent facility's EOC Committee minutes for the Brunswick and Macon CBOCs.
Closure Date:
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| 13-01669-270 | Combined Assessment Program Review of the Jesse Brown VA Medical Center, Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include how the service and physician responsible for the patient are determined.
Closure Date:
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
3 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing, of PRs when transfusions do not meet criteria, and of inspections by government or private (peer) entities.
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 Infection Prevention and Control Committee minutes reflect discussion of high-risk areas and actions implemented to address these areas.
Closure Date:
6 We recommended that processes be strengthened to ensure that all Infection Prevention and Control Committee members or their designees participate in meetings and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that Infection Prevention and Control Committee minutes reflect discussion of hand hygiene compliance, follow-up actions, and action results.
Closure Date:
8 We recommended that processes be strengthened to ensure that monthly hemodialysis dialysate testing includes endotoxins.
Closure Date:
9 We recommended that processes be strengthened to ensure that SPS employees receive annual competency assessments for all RME items they reprocess.
Closure Date:
10 We recommended that processes be strengthened to ensure that SPS temperature and humidity level monitoring is consistently documented and that compliance be monitored.
Closure Date:
11 We recommended that managers initiate actions to address the identified deficiency and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
12 We recommended that the facility pressure ulcer policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that Infection Prevention and Control Committee minutes include pressure ulcer data analysis.
Closure Date:
14 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
15 We recommended that nursing managers monitor the staffing methodology that was implemented in February 2013.
Closure Date:
16 We recommended that the CSC continues to meet and ensures appropriate oversight of construction and renovation activities.
Closure Date:
17 We recommended that processes be strengthened to ensure that all CSC members or their designees consistently attend required meetings and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that a contractor tuberculosis risk assessment is conducted prior to construction project initiation.
Closure Date:
19 We recommended that processes be strengthened to ensure that construction site inspections are conducted at the facility's required frequency and documented.
Closure Date:
20 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:
21 We recommended that processes be strengthened to ensure that contractor safety training is verified prior to project initiation.
Closure Date:
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| 12-00040-268 | Vet Center Contracted Care Program Review | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders receive, review, and approve psychosocial assessments and counseling plans prior to authorizing contracted counseling services.
2 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct and document client assessments after 1 year of eligibility for contracted client services.
3 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct annual onsite quality reviews for contractors who participate in the Contract for Fee Program.
4 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service uses a standard template that includes terms and conditions that are consistent with those in the Readjustment Counseling Service policy.
5 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service maintains and monitors counseling service contracts in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
6 We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders authorize contracted counseling services in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
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| 13-00026-279 | Community Based Outpatient Clinic Reviews at VA Pittsburgh Healthcare System, Pittsburgh, PA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
3 We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
4 We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Fayette County and Washington County CBOCs.
Closure Date:
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| 13-00026-281 | Community Based Outpatient Clinic Reviews at Louis A. Johnson VA Medical Center, Clarksburg, WV | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommended that biohazardous waste containers are available in the CBOC.
Closure Date:
3 We recommended that managers maintain a written, current inventory of hazardous materials at the CBOC.
Closure Date:
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| 13-02235-277 | Healthcare Inspection - Alleged Patient Rights, Quality of Care, and Other Issues, VA Puget Sound Health Care System, Seattle, Washington | Hotline Healthcare Inspection | ||
1 We recommended the System Director ensure the Women Veterans Program Manager provides chaperone policy education to all system primary care clinics and monitors compliance.
Closure Date:
2 We recommended the System Director ensure all staff are informed about the VHA requirement to report allegations of patient abuse and educated on the processes for reporting the alleged abuse.
Closure Date:
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| 13-01671-262 | Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that ECC membership includes all required disciplines.
Closure Date:
2 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of non-VA purchased care are consistently scanned into EHRs.
Closure Date:
4 We recommended that processes be strengthened to ensure that results of compliance with RME SOPs are reported to the RME Management Committee and the MEB.
Closure Date:
5 We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive initial RME training and annual competency assessments.
Closure Date:
6 We recommended that processes be strengthened to ensure that manufacturers’ instructions are available for all RME items, that RME is reprocessed at the specified temperature, and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that SPS sterile storage area temperature and humidity levels are consistently monitored and maintained within acceptable levels.
Closure Date:
8 We recommended that facility policy be amended to include the requirement that CS inspectors receive annual updates regarding problematic issues identified through external survey findings and other quality control measures and that processes be strengthened to ensure that CS inspectors receive annual updates.
Closure Date:
9 We recommended that the facility develop instructions for inspections of automated dispensing machines and that processes be strengthened to ensure that monthly findings summaries are provided to the facility Director and that quarterly trend reports clearly summarize discrepancies and problematic trends and identify potential areas for improvement.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors’ appointments state the end date of their term and that CS inspectors’ terms do not exceed 3 years.
Closure Date:
11 We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS are conducted in accordance with VHA requirements and include all required elements and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
13 We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
14 We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
Closure Date:
15 We recommended that processes be strengthened to ensure that HPC inpatients’ pain is consistently assessed whenever vital signs are obtained and results documented in EHRs and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that HPC inpatients’ pain assessments are documented in EHRs using approved note titles and that compliance be monitored.
Closure Date:
17 We recommended that the interprofessional pressure ulcer committee includes a certified wound care specialist.
Closure Date:
18 We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer location and stage and perform and document all required daily activities/inspections for patients with pressure ulcers and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
Closure Date:
20 We recommended that processes be strengthened to ensure that acute care staff perform and document skin inspections and risk scales at discharge and that compliance be monitored.
Closure Date:
21 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to discharge and that compliance be monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients and/or their caregivers and that compliance be monitored.
Closure Date:
23 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
24 We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.
Closure Date:
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11259