Recommendations
1011
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00026-316 | Community Based Outpatient Clinic Reviews at Sheridan VA Healthcare System, Sheridan, WY | 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 MSDS are kept current at the Casper and Riverton CBOCs and that staff is trained in accessing MSDS for hazardous chemicals in the clinical area at the Casper CBOC.
Closure Date:
3 We recommended that managers ensure all exit routes are clearly identified at the Riverton CBOC.
Closure Date:
4 We recommended that testing of the panic alarm system is documented at the Casper and Riverton CBOCs.
Closure Date:
5 We recommended that the Chief of OI&T implements required measures at the Casper CBOC.
Closure Date:
6 We recommended that EOC deficiencies are tracked, trended, and corrected at the Casper and Riverton CBOCs.
Closure Date:
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| 12-03887-319 | Healthcare Inspection – Inadequate Staffing and Poor Patient Flow in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop action plans that address emergency department patient flow and length of stay, including specialty bed access.
Closure Date:
2 We recommended that the Facility Director develop an emergency department staffing policy that includes a contingency plan for additional physician and nurse staffing when patient care demands exceed available staffing resources.
Closure Date:
3 We recommended that the Facility Director ensure that data collection and the reporting process are strengthened.
Closure Date:
4 We recommend that the Facility director ensure that a local diversion policy is developed and implemented.
Closure Date:
5 We recommended that the Facility Director ensure that the patient flow committee meets regularly, membership is reviewed for appropriateness, and follow-up actions are monitored.
Closure Date:
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| 12-02708-301 | Review of Alleged System Duplication in VA’s Virtual Office of Acquisition Software Development Project | Audit | ||
1 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
Closure Date:
2 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Closure Date:
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| 13-00026-314 | Community Based Outpatient Clinic Reviews at James A. Haley Veterans' Hospital, Tampa, FL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
3 We recommended that managers ensure that fire drills be completed at the Zephyrhills CBOC as required.
Closure Date:
4 We recommended that managers ensure that signage is installed at the New Port Richey and Zephyrhills CBOCs that clearly identifies fire extinguisher locations.
Closure Date:
5 We recommended that managers ensure that patient privacy is maintained as required at the New Port Richey and Zephyrhills CBOCs.
Closure Date:
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| 13-01498-318 | Healthcare Inspection – An Unexpected Death in a Mental Health Treatment Program, VA New Jersey Health Care System, Lyons, New Jersey | Hotline Healthcare Inspection | ||
1 We recommended that that the Health Care System Director ensures that the Mental Health Residential Rehabilitation Treatment Program complies with local and VHA Mental Health Residential Rehabilitation Treatment Program Safe Medication Management policy requirements.
Closure Date:
2 We recommended that the Health Care System Director ensure that Mental Health Residential Rehabilitation Treatment Program documentation is individualized, timely, and includes required elements.
Closure Date:
3 We recommended that the Health Care System Director ensure that Mental Health leadership provides appropriate professional support for Mental Health Residential Rehabilitation Treatment Program mid-level providers.
Closure Date:
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| 12-04524-321 | Audit of VBA's Veterans' Retraining Assistance Program Participation | Audit | ||
1 We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they must monitor VA students' attendance and grades for satisfactory academic progress.
Closure Date:
2 We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they are required to report VA students' changes in enrollment to VBA within 30 days.
Closure Date:
3 We recommend the Under Secretary for Benefits revise the certifying official handbook to state a veteran's signed statement should not be used as the only means of verifying attendance.
Closure Date:
4 We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they need to accurately report credit hours and class terms in the VA ONline Certification of Enrollment system.
Closure Date:
5 We recommend the Under Secretary for Benefits include language on the Interactive Voice Response scripts to warn veterans of the potential penalty for certifying false enrollment information.
Closure Date:
6 We recommend the Under Secretary for Benefits implement a plan to monitor veterans currently enrolled at the schools that had their approval withdrawn or suspended to ensure they meet Veterans Retraining Assistance Program full-time attendance requirements and are making positive progress towards program completion.
Closure Date:
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| 13-02599-311 | Healthcare Inspection – Laboratory Delays and Alleged Staff Training Issues, Memphis VA Medical Center, Memphis, Tennessee | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that processes be strengthened to ensure that laboratory turnaround times adhere to facility and VISN 9 expectations.
Closure Date:
2 We recommended that the Facility Director ensure that policies and processes are put in place to establish consistent and appropriate methods for data collection and analysis of laboratory turnaround times.
Closure Date:
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| 13-00026-317 | Community Based Outpatient Clinic Reviews at the Fargo VA Health Care System, Fargo, ND | 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 administer pneumococcal vaccines when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
4 We recommended that auditory privacy is maintained during the check-in process at the Bemidji and Fergus Falls CBOCs.
Closure Date:
5 We recommended that the Chief of OI&T implements required measures at the Bemidji and Fergus Falls CBOCs.
Closure Date:
6 We recommended that managers develop a local policy for MH emergencies that reflects the current risk, practice, and capability at the Bemidji CBOC.
Closure Date:
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| 13-02313-310 | Combined Assessment Program Review of the Amarillo VA Health Care System, Amarillo, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that senior leaders routinely discuss the facility's Inpatient Evaluation Center data and ensure the discussions are documented in the minutes of a senior-level committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that results of completed FPPEs for newly hired licensed independent practitioners are reported to the MEC.
Closure Date:
3 We recommended that the local observation bed policy be revised to include how the service or the physician responsible for the patient is determined, that each admission must have a limited severity of illness, and assessment expectations.
Closure Date:
4 We recommended that the facility establish a policy that defines Special Care Committee responsibilities, including code episode reviews and data collection.
Closure Date:
5 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
Closure Date:
6 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing, of peer reviews, and of inspections by government or private (peer) entities.
Closure Date:
7 We recommended that processes be strengthened to ensure that medications are secured at all times and only pharmaceutical items are stored in medication refrigerators and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PCCT includes an assigned administrative support person.
Closure Date:
9 We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
Closure Date:
10 We recommended that processes be strengthened to ensure that advance directive screening is performed upon admission for all HPC inpatients.
Closure Date:
11 We recommended that processes be strengthened to ensure that a Hospice/End of Life Care Plan is completed for all HPC inpatients.
Closure Date:
12 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections and/or daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
14 We recommended that the facility establish ongoing 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 December 2012.
Closure Date:
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| 13-01976-312 | Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut | 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.
2 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that the data collected from resuscitation episodes are critically analyzed.
3 We recommended that the facility implement a quality control policy for scanning.
4 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
5 We recommended that processes be strengthened to ensure that EOC Committee minutes include results of EOC rounds, identify who is responsible for correcting environmental deficiencies, and track deficiencies to closure.
6 We recommended that processes be strengthened to ensure that restrooms and showers on inpatient units are clean.
7 We recommended that processes be strengthened to ensure that public restrooms and elevators are clean, that public restrooms are free from environmental safety hazards, and that automatic door opening switches in all public restrooms are operational.
8 We recommended that managers initiate actions to address the four identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
9 We recommended that processes be implemented to ensure that quarterly trend reports are provided timely to the facility Director and that trending and analysis of the data includes all elements required by VHA policy.
10 We recommended that processes be strengthened to ensure that all required non-pharmacy and pharmacy areas with CS are inspected monthly.
11 We recommended that processes be strengthened to ensure that inspectors validate 2 transfers of CS from 1 storage area to another area and that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled.
12 We recommended that the PCCT includes a dedicated administrative support person and psychologist or other mental health provider.
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.
14 We recommended that the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
15 We recommended that processes be strengthened to ensure that acute care staff accurately document PU location, stage, risk scale score, and date acquired.
16 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections for patients at risk for or with PUs and consistently revise prevention plans if the patients’ risk levels change.
17 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.
18 We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the PU risk scale, how to conduct a complete skin assessment, and how to accurately document findings.
19 We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection.
20 We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.
21 We recommended that nurse managers reassess the target nursing hours per patient day for the medical intensive care unit to more accurately plan for staffing and evaluate the actual staffing provided.
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11259