Recommendations
1151
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00026-10 | Community Based Outpatient Clinic Reviews at Kansas City VA Medical Center, Kansas City, MO | Comprehensive Healthcare Inspection Program | ||
| 13-00133-12 | Healthcare Inspection – Alleged Improper Opioid Prescription Renewal Practices, San Francisco VA Medical Center, San Francisco, California | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure providers comply with all elements of the management of chronic pain patients on opioid therapy, as required by VHA and the VA/DoD Clinical Guideline.
Closure Date:
2 We recommended that the Facility Director ensures that the Narcotic Instructions Note is reevaluated for appropriate use in the clinic and that providers comply with established protocol.
Closure Date:
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| 13-00026-08 | Community Based Outpatient Clinic Reviews at Richard L. Roudebush VA Medical Center, Indianapolis, IN | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified 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 pneumococcal vaccines when indicated.
Closure Date:
4 We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
5 We recommended that handicap parking spaces meet ADA requirements at the Terre Haute CBOC.
Closure Date:
6 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and that all identified issues are tracked, trended, and corrected at the Terre Haute CBOC.
Closure Date:
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| 13-00026-07 | Community Based Outpatient Clinic Reviews at VA Greater Los Angeles Healthcare System, Los Angeles, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
2 We recommended that the Antelope Valley CBOC IT closet is maintained according to IT security standards.
Closure Date:
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| 13-02640-06 | Combined Assessment Program Review of the VA Greater Los Angeles Healthcare System, Los Angeles, California | 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 and that quarterly PRC summary reports are consistently presented to the MEC.
2 We recommended that processes be strengthened to ensure that
FPPE results for newly hired licensed independent practitioners are consistently reported to the Professional Standards Board.
3 We recommended that the local observation bed policy be
revised to include that each observation patient must have a focused goal for the period of observation and that each admission must have a limited severity of illness.
4 We recommended that processes be strengthened to ensure that
continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
5 We recommended that processes be strengthened to ensure that
the Cardiac Arrest Committee reviews each code episode.
6 We recommended that the MRC provide oversight and coordination of the review of the quality of entries in EHRs.
7 We recommended that the facility continue the recently implemented process for scanning the results of non-VA purchased care into EHRs and that compliance be monitored.
8 We recommended that processes be strengthened to ensure that representatives from Surgery and Anesthesia Services consistently attend Blood Usage Committee meetings and that the results of proficiency testing and inspections by government and private entities are routinely reported to the Blood Usage Committee.
9 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in the Inpatient Operations Council, MEC, and MRC.
10 We recommended that processes be strengthened to ensure that ventilation system covers are clean, housekeeping closets and soiled utility rooms are locked, and emergency call system cords are functional and that compliance be monitored.
11 We recommended that the facility repair the laminate and floor in hemodialysis to ensure infection prevention and safety standards are maintained.
12 We recommended that processes be strengthened to ensure that SPS sterile storage area humidity is maintained within acceptable levels and that compliance be monitored.
13 We recommended that facility policy be amended to include
elements required by VHA policy related to physical counts of automated dispensing units, quarterly trend reports, and pharmacy drug destruction.
14 We recommended that managers initiate actions to address identified security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are addressed and corrected.
15 We recommended that processes be strengthened to ensure
that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
16 We recommended that processes be strengthened to ensure that CS inspectors perform weekly inventory verifications of automated dispensing machines and that compliance be monitored.
17 We recommended that processes be strengthened to ensure
that quarterly trend reports are completed and provided to the facility Director.
18 We recommended that processes be strengthened to ensure
that all CS inspectors have current CS Drug-Diversion Inspection Certification and that inspectors receive annual updates and/or refresher training and that compliance be monitored.
19 We recommended that processes be strengthened to ensure
that inspectors do not exceed the 3-year term limit and are given a 1-year hiatus before being reappointed and that compliance be monitored.
20 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
21 We recommended that processes be strengthened to ensure
that all pharmacy areas, including the emergency drug cache, are inspected monthly and that compliance be monitored.
22 We recommended that processes be strengthened to ensure
that inspectors perform drug destruction and audit trail verification and that compliance be monitored.
23 We recommended that the facility Director consider consulting
with Pharmacy Benefits Management to ensure the facility’s CS inspection program complies with VHA policy.
24 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.
25 We recommended that processes be strengthened to ensure
that acute care staff accurately document location, stage, and/or risk scale score for all patients with pressure ulcers and that compliance be monitored.
26 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 being discharged and that compliance be monitored.
27 We recommended that the nurse manager reassess the target
nursing hours per patient day for unit 213-2 to more accurately plan for staffing and evaluate the actual staffing provided.
28 We recommended that processes be strengthened to ensure that all designated employees complete annual N95 respirator fit testing and that compliance be monitored.
29 We recommended that processes be strengthened to ensure
that all employees who work on locked MH units complete annual environmental hazards training and that compliance be monitored.
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| 13-02638-01 | Combined Assessment Program Review of the Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that sterile supply storage and soiled utility areas are secured at all times.
Closure Date:
2 We recommended that the facility develop instructions for inspections of automated dispensing machines.
Closure Date:
3 We recommended that processes be strengthened to ensure that quarterly trend reports include problematic trends and potential areas for improvement.
Closure Date:
4 We recommended that processes be strengthened to ensure that CS inspectors receive annual CS updates and/or refresher training.
Closure Date:
5 We recommended that processes be strengthened to ensure that CS inspectors consistently verify the number of prescription pads and that compliance be monitored.
Closure Date:
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| 13-00026-352 | Community Based Outpatient Clinic Reviews at VA Western New York Healthcare System, Buffalo, NY | 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 required timeframe and that notification is documented in the EHR.
Closure Date:
2 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:
3 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
4 We recommended that the Executive Committee of the Medical Staff grants privileges consistent with the services provided at the Lackawanna and Niagara Falls CBOCs.
Closure Date:
5 We recommended that laboratory specimens are secured during transport from the Lackawanna and Niagara Falls CBOCs to the parent facility to prevent the disclosure of patients PII.
Closure Date:
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| 13-00505-348 | Healthcare Inspection – Emergency Department Patient Deaths’ Memphis VAMC, Memphis, Tennessee | Hotline Healthcare Inspection | ||
1 We recommended that Facility Director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3.
Closure Date:
2 We recommended that the Facility Director ensure that root cause analysis action plans are documented, monitored, and completed promptly.
Closure Date:
3 We recommended that the Facility Director ensure that patients are appropriately monitored in all emergency department rooms.
Closure Date:
4 We recommended that the Facility Director ensure that unit-specific competency assessments are completed for emergency department nursing staff.
Closure Date:
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| 12-04046-307 | Review of VA's Management of Health Care Center Leases | Audit | ||
1 We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, establish adequate guidance for the procurement oflarge-scale build-to-lease facilities.
2 We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, provide realistic and justifiable timelines for award,construction, and activation of the Health Care Center leases.
3 We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, ensure supporting analyses and key decisions regarding theHealth Care Center leases are supported and documented.
4 We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, establish central cost tracking to ensure transparency andaccurate reporting on Health Care Center expenditures.
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| 11-00330-338 | Audit of Selected VHA Non-Institutional Purchased Home Care Services | Audit | ||
1 We recommended the Under Secretary for Health ensure VA medical facilities apply standardized eligibility criteria and ensure purchased home care review processes are not improperly used to limit access to purchase home care services.
Closure Date:
2 We recommended the Under Secretary for Health ensure VA medical facilities maintain waiting lists for purchased home care services and assess eligible veterans¿ unmet needs for services.
Closure Date:
3 We recommended the Under Secretary for Health correct eligibility information in VA's Veterans' Health Care Benefits Overview booklet and on the Office of Geriatrics and Extended Care's Web site to be consistent with VHA policy and indicate veterans do not have to be homebound to be eligible for purchased skilled care services.
Closure Date:
4 We recommended the Under Secretary for Health strengthen non-institutional care program oversight to monitor budgeted and expended funding for purchased home care services and ensure average daily census performance monitoring data is accurate, reliable, and transparent.
Closure Date:
5 We recommended the Under Secretary for Health implement effective performance measures for purchased home care services to ensure VA medical facilities do not improperly limit access to services.
Closure Date:
6 We recommended the Under Secretary for Health implement management controls to ensure VA medical facilities adhere to the Veterans Health Administration's requirements related to the identification and management of ineligible and high-risk purchased home care agencies.
Closure Date:
7 We recommended the Under Secretary for Health clarify the Veterans Health Administration's purchased home care policies and provide appropriate VA medical facility staff training on the proper use of eligible purchased home care agencies, exemptions, and the monitoring of high-risk agencies.
Closure Date:
8 We recommended the Under Secretary for Health establish effective controls and monitors to ensure providers properly document orders and fee staff properly verifies the appropriateness of the services in accordance with VA fee policies before they pay for purchased home care services.
Closure Date:
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11259