Recommendations
987
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00894-216 | Combined Assessment Program Review of the VA Manila Outpatient Clinic, Manila, Philippines | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility initiate monitoring of the copy and paste function.
Closure Date:
2 We recommended that the Peer Review Committee meets at least quarterly or that a notation be made if there are no cases to discuss for the quarter.
Closure Date:
3 We recommended that processes be strengthened to ensure that EOC and Infection Prevention/Control Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
Closure Date:
4 We recommended that processes be strengthened to ensure that infection prevention risk assessments are conducted.
Closure Date:
5 We recommended that processes be strengthened to ensure that fire extinguisher inspections are conducted monthly and documented.
Closure Date:
6 We recommended that a process be implemented to ensure that laboratory specimens are transported in a secure manner.
Closure Date:
7 We recommended that processes be strengthened to ensure that CS inspectors verify hard copy prescriptions for 10 percent of the schedule II drugs dispensed in the outpatient pharmacy and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that patients at high risk for suicide and/or their families receive a copy of the safety plan.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
10 We recommended that the facility develop and implement a policy related to screening and referral for at-risk diabetic patients.
Closure Date:
11 We recommended that processes be strengthened to ensure that diabetic patients receive annual risk assessments with risk level scores and that the assessments are documented in the EHRs.
Closure Date:
12 We recommended that processes be strengthened to ensure that diabetic patients at moderate or high risk receive foot exams at each routine primary care visit.
Closure Date:
13 We recommended that processes be strengthened to ensure that patients are consistently notified of critical/abnormal test results and that notification is documented in the EHRs.
Closure Date:
14 We recommended that processes be strengthened to ensure that debriefings occur after incidents of disruptive or violent behavior.
Closure Date:
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| 13-00886-210 | Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
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 clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
4 We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes and that code sheets are scanned into the EHRs.
Closure Date:
5 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
Closure Date:
6 We recommended that processes be strengthened to ensure that sensitive patient information is secured on computer screens in the ED.
Closure Date:
7 We recommended that processes be strengthened to ensure that medical equipment in the ED is terminally cleaned after patient discharge.
Closure Date:
8 We recommended that processes be strengthened to ensure that supplies and equipment in the East Orange PT clinic are properly stored.
Closure Date:
9 We recommended that facility policy be amended to address that the CS Coordinator PD or functional statement must include CS inspection and coordination, to include that the CS Coordinator must have complete understanding of CS policies and VHA inspection process, and to include requirements for new CS inspector orientation and annual training thereafter.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
12 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
13 We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
Closure Date:
14 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:
15 We recommended that processes be strengthened to ensure that home oxygen program patients deemed to be high risk have fire risk assessments completed and that 3-month follow-up evaluations are completed for all home oxygen program patients.
Closure Date:
16 We recommended that unit 9A's expert panel include all required members.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
18 We recommended that managers initiate protected peer review for the identified patient and complete any recommended review actions.
Closure Date:
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| 13-00026-213 | Community Based Outpatient Clinic Reviews at Central Texas Veterans Health Care System, Temple, TX, and VA Texas Valley Coastal Bend Health Care System, Harlingen, TX | 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.
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.
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
5 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
6 We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
7 We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Cedar Park CBOC.
8 We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Corpus Christi Satellite, Harlingen OPC, and Laredo CBOC.
9 We recommended that signage is installed at the Corpus Christi Satellite, Harlingen OPC, and McAllen Satellite to clearly identify the location of fire extinguishers.
10 We recommended that a panic alarm system is installed at the Laredo CBOC.
11 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispen
12 We recommended that the placement of the telecommunications network beevaluated and that appropriate safety measures are implemented at theCorpus Christi Satellite.
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| 13-00432-217 | Combined Assessment Program Review of the Spokane VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
| 13-01741-215 | Combined Assessment Program Summary Report - Evaluation of Colorectal Cancer Screening and Follow-Up 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 communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Closure Date:
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| 12-04328-211 | Inspection of VA Regional Office Wilmington, Deleware | Review | ||
1 We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and timely schedule medical reexaminations when the reminder notifications generate.
Closure Date:
2 We recommend the Wilmington Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits when appropriate.
Closure Date:
3 We recommend the Wilmington VA Regional Office Director conduct a review of the 57 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
4 We recommend the Wilmington VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers under the VA Regional Office's jurisdiction.
Closure Date:
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| 13-00026-212 | Community Based Outpatient Clinic Reviews at Oklahoma City VA Medical Center, Oklahoma City, OK | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are strengthened 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 processes are strengthened to 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 managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that the PSB grants setting-specific clinical privileges for all providers at the Ardmore and Enid CBOCs.
Closure Date:
6 We recommended that handicapped parking spaces at the Enid CBOC meet ADA requirements for parking space identification.
Closure Date:
7 We recommended that restroom access is improved for disabled veterans at the Ardmore and Enid CBOCs.
Closure Date:
8 We recommended that laboratory specimens are secured during transport from the Ardmore and Enid CBOCs to the parent facility.
Closure Date:
9 We recommended that the IT server closets are maintained according to IT safety and security standards at the Ardmore and Enid CBOCs.
Closure Date:
10 We recommended that managers ensure that an AED is available at the Enid CBOC.
Closure Date:
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| 13-00026-207 | Community Based Outpatient Clinic Reviews at North Florida/South Georgia Veterans Health System, Gainesville, FL | Comprehensive Healthcare Inspection Program | ||
| 13-00376-201 | Combined Assessment Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the results of FPPEs for newly hired LIPs are consistently reported to the ECOMS.
Closure Date:
2 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed.
Closure Date:
4 We recommended that processes be strengthened to ensure that the review of EHR quality includes all services
Closure Date:
5 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient care equipment is consistently cleaned between patient use.
Closure Date:
7 We recommended that processes be strengthened to ensure that gloves in all sizes and gowns are available in the therapy clinic areas.
Closure Date:
8 We recommended that processes be strengthened to ensure that inspectors are sufficiently rotated in inspection assignments and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that inspectors do not participate in inspections beyond their 3-year appointment expiration date and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated nurse, social worker, and administrative support person and a 0.25 FTE psychologist or other MH provider.
Closure Date:
11 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:
12 We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
Closure Date:
13 We recommended that unit 134-3Cs nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
14 We recommended that managers initiate protected PR for the identified patient and complete any recommended review actions.
Closure Date:
15 We recommended that processes be strengthened to ensure that routine construction site inspections are conducted by the required CSC members, include all required elements, and are documented.
Closure Date:
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| 13-00889-206 | Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia | Comprehensive Healthcare Inspection Program | ||
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