Recommendations
1085
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 12-01860-237 | Audit of Non-Purchase Card Micro-Purchases | Audit | ||
1 We recommended the Under Secretary for Health collaborate with the VA Office of Management to establish policies and procedures to regularly identify and evaluate the universe of micro-purchases and non-purchase card micro-purchases to monitor the level of Veterans Health Administration use of purchase cards.
Closure Date:
2 We recommended the Under Secretary for Health establish annual and long-term strategic goals to increase the percentage of VA medical facility micro-purchases made with purchase cards.
Closure Date:
3 We recommended the Under Secretary for Health implement mechanisms to ensure purchasers and approvers adequately consider purchase card use for micro-purchases.
Closure Date:
4 We recommended the Under Secretary for Health modify policies and procedures requiring Veterans Integrated Service Networks to perform oversight of non-purchase card micro-purchases that identifies opportunities for increased use of purchase cards.
Closure Date:
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| 13-01445-271 | Inspection of VA Regional Office Milwaukee, Wisconsin | Review | ||
| 13-01670-269 | Combined Assessment Program Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that VA Police conduct annual physical security surveys of the pharmacy areas and that any identified deficiencies be corrected.
Closure Date:
2 We recommended that processes be strengthened to ensure that the PCCT includes an administrative support person and a dedicated psychologist or other MH professional.
Closure Date:
3 We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer was acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
6 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:
7 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology that was implemented in December 2012.
Closure Date:
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| 13-01675-266 | Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the PCCT includes a 0.25 full-time employee equivalent psychologist or other mental health provider.
Closure Date:
2 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon discharge and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, assessments for change in condition, and/or revisions to prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
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| 13-00899-261 | Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired LIPs are consistently initiated and that results are consistently reported to the MEC.
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
3 We recommended that processes be strengthened to ensure that patient care areas and furnishings are clean and that compliance be monitored.
4 We recommended that processes be strengthened to ensure that inpatient rooms and ED medical equipment are consistently terminally cleaned and that compliance be monitored.
5 We recommended that processes be strengthened to ensure that OR employees who perform IUS receive initial training.
6 We recommended that processes be strengthened to ensure that weekly inventories of automated dispensing machines are consistently conducted and that compliance be monitored.
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated nursing representative.
9 We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
10 We recommended that processes be strengthened to ensure that acute care staff perform and document a skin inspection and risk scale prior to discharge and that compliance be monitored.
11 We recommended that processes be strengthened to ensure that acute care staff accurately document PU location, stage, risk scale score, and data acquired and that compliance be monitored.
12 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections and risk scales for patients at risk for or with PUs and that compliance be monitored.
13 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.
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| 13-00670-265 | Healthcare Inspection - Review of Circumstances Leading to a Pause in Providing Inpatient Care, VA Northern Indiana Healthcare System, Fort Wayne, Indiana | Hotline Healthcare Inspection | ||
1 We recommended that VHA develop policy for guidance when major clinical services are paused at a VA facility.
Closure Date:
2 We recommended that the VISN Director ensure that a review of the facility ICU level of care and support services is completed to determine the appropriate designation.
Closure Date:
3 We recommended that the VISN Director ensure that qualified clinical staff are available to provide care.
Closure Date:
4 We recommended that the VANIHCS Director ensure that efforts continue to recruit qualified staff for vacant leadership positions.
Closure Date:
5 We recommended that the VANIHCS Director ensure that nurse competencies are consistently completed and validated annually.
Closure Date:
6 We recommended that the VANIHCS Director ensure that the facility fully implement the nurse staffing methodology and complete all required steps.
Closure Date:
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| 13-01987-263 | Healthcare Inspection - Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.
Closure Date:
2 We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.
Closure Date:
3 We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
Closure Date:
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| 13-01189-267 | Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
Closure Date:
2 We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
Closure Date:
3 We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
Closure Date:
4 We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Closure Date:
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11259