Recommendations
1011
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03077-122 | Combined Assessment Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
| 12-04191-123 | Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that
results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that
continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure that
code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the code.
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 clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
6 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
Closure Date:
7 We recommended that processes be strengthened to ensure IC Committee minutes reflect follow-up on actions that were implemented to address identified problems.
Closure Date:
8 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
Closure Date:
9 We recommended that processes be strengthened to ensure that KT clinic staff consistently change linens and clean equipment between patient use.
Closure Date:
10 We recommended that the stained privacy curtains in the KT clinic be replaced and that privacy curtains be routinely inspected and replaced as needed.
Closure Date:
11 We recommended that processes be strengthened to ensure that medications in the PT clinic are secured at all times.
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 the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
15 We recommended that the facility expert panel review unit 34's and CLC unit 3's expert panels' recommendations.
Closure Date:
16 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
17 We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
Closure Date:
18 We recommended that processes be strengthened to ensure that IC staff conduct contractor TB risk assessments prior to construction project initiation.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor TB skin test results are documented.
Closure Date:
20 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
Closure Date:
21 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
| ||||
| 12-03854-115 | Community Based Outpatient Clinic Reviews at William S. Middleton Memorial Veterans Hospital, Madison, WI | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
| ||||
| 12-03753-121 | Healthcare Inspection – Issues at a VA Mid South Healthcare Network Dental Clinic | Hotline Healthcare Inspection | ||
1 We recommend that the System Director ensure that dental clinic staff have adequate knowledge regarding periodontal disease.
Closure Date:
2 We recommend that the System Director ensure treatment plans are developed, revised, followed, and documented.
Closure Date:
3 We recommend that the System Director develop and implement a plan to improve communication and professional interaction among dental clinic staff.
Closure Date:
| ||||
| 12-03851-117 | Community Based Outpatient Clinic Reviews at Marion VA Medical Center, Marion, IL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the parent Facility Director ensures that each CBOC is assigned a WH Liaison and that the WH Liaison collaborates with the Women Veterans Program Manager.
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 tetanus 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 service chiefs' documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Farmington and West Plains CBOCs.
Closure Date:
6 We recommended that the PSB grants LIPs setting-specific privileges that are consistent with the services provided at the Farmington and West Plains CBOCs.
Closure Date:
7 We recommended that signage is installed at the West Plains CBOC to clearly identify the location of fire extinguishers.
Closure Date:
8 We recommended that fire safety inspections are conducted annually at the West Plains CBOC.
Closure Date:
9 We recommended that processes are strengthened to ensure patient privacy is maintained during examination at the Farmington CBOC.
Closure Date:
10 We recommended that managers ensure that AEDs are checked daily at the West Plains CBOC, as required by facility policy.
Closure Date:
| ||||
| 12-03477-118 | Inspection of Veterans Service Center Cheyenne, Wyoming | Review | ||
| 12-03851-102 | Community Based Outpatient Clinic Reviews at John J. Pershing VA Medical Center, Poplar Bluff, MO | Comprehensive Healthcare Inspection Program | ||
| 12-03854-114 | Community Based Outpatient Clinic Reviews at Iowa City VA Health Care System, Iowa City, IA | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that the FPPE review for the Cedar Rapids CBOC providers is included in the Clinical Executive Board meeting minutes.
Closure Date:
| ||||
| 12-03852-109 | Community Based Outpatient Clinic Reviews at Spokane VA Medical Center, Spokane, WA | Comprehensive Healthcare Inspection Program | ||
| 12-03850-112 | Community Based Outpatient Clinic Reviews at Charles George VA Medical Center, Asheville, NC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
| ||||
11259