Recommendations
1011
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03743-184 | Healthcare Inspection - Alleged Questionable Surgical Care in a VA Health Care System | Hotline Healthcare Inspection | ||
1 We recommended that the system Director ensure that the two alleged near misses are referred to quality management staff to determine if action should have been taken.
Closure Date:
2 We recommended that the system Director consult with Regional Counsel regarding possible clinical disclosure to the patient for whom quality of surgical technique concerns were identified.
Closure Date:
3 We recommended that the system Director ensure that initial focused professional practice evaluations are completed on all newly hired providers.
Closure Date:
4 We recommended that the system Director ensure that privileges are facility and provider specific for all providers.
Closure Date:
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| 13-01744-187 | Combined Assessment Program Summary Report – Evaluation of Nurse Staffing in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
| 13-01742-188 | Combined Assessment Program Summary Report – Evaluation of Mental Health Treatment Continuity at Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that facilities take action to improve post-discharge follow-up for MH patients, particularly those who were identified as high risk for suicide.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that clinicians consistently follow the required processes for patients who fail to report for scheduled MH appointments and document actions taken.
Closure Date:
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| 12-03885-168 | Insepction of VA Regional Office Boise, Idaho | Review | ||
1 We recommend the Boise VA Regional Office Director develop and implement a plan to ensure staff include recommendations for identified problems in their Systematic Analyses of Operations.
Closure Date:
2 We recommend the Boise VA Regional Office Director develop and implement a plan to monitor the effectiveness of training and the local checklist to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans¿ entitlement to mental health treatment when previous decisions did not address this issue as required.
Closure Date:
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| 13-00026-177 | Community Based Outpatient Clinic Reviews at Robley Rex VA Medical Center, Louisville, KY | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that managers ensure that patients with 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 pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
5 We recommended that FPPEs are initiated for all providers who request new privileges at the Scott County CBOC.
Closure Date:
6 We recommended that the facility ensure annual fire drills are completed at the Carroll County and Scott County CBOCs.
Closure Date:
7 We recommended that all identified EOC deficiencies at the Carroll County and Scott County CBOCs are tracked and trended until corrected.
Closure Date:
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| 12-01480-183 | Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2012 | Comprehensive Healthcare Inspection Program | ||
| 12-04525-170 | Inspection of VA Regional Office Denver, Colorado | Review | ||
1 We recommend the Denver VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
Closure Date:
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| 13-00026-176 | Community Based Outpatient Clinic Reviews at Central Arkansas Veterans Healthcare System, Little Rock, AR, and G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS | 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 cervical cancer screening results are documented in the patient's EHR.
Closure Date:
3 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:
4 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
5 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
6 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
7 We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Russellville and Searcy CBOCs.
Closure Date:
| ||||
| 13-00994-180 | Healthcare Inspection - Legionnaires’ Disease at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Hotline Healthcare Inspection | ||
1 We recommended that the VA Pittsburgh Healthcare System Director ensure that any disinfectant system in use for Legionella prevention is monitored and maintained in accordance with manufacturer’s instructions.
Closure Date:
2 We recommended that the VA Pittsburgh Healthcare System Director ensure routine flushing of hot-water faucets and showerheads.
Closure Date:
3 We recommended that the VA Pittsburgh Healthcare System Director ensure close coordination between the Infection Prevention Team and Facilities Management Service staff.
Closure Date:
4 We recommended that the VA Pittsburgh Healthcare System Director ensure that when environmental cultures are positive, actions taken comply with Veterans Health Administration guidelines.
Closure Date:
5 We recommended that the VA Pittsburgh Healthcare System Director ensure that all healthcare-associated pneumonia patients are tested for Legionella infection.
Closure Date:
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| 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 | ||
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