Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-04700-119 | Combined Assessment Program Review of the Edward Hines, Jr. VA Hospital, Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that designated employees maintain a log of individuals entering the facility between 9:00 p.m. and 5:00 a.m. and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms or post signage indicating that rooms are not operational and monitor compliance.
Closure Date:
3 We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
Closure Date:
4 We recommended that employees secure sensitive patient information at all times and that facility managers monitor compliance.
Closure Date:
5 We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes an annual written test.
Closure Date:
6 We recommended that facility managers ensure completion and documentation of periodic surface sampling in all required areas and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure employees perform and document monthly cleaning of ceilings, walls, and storage shelving in all compounding areas and monitor compliance.
Closure Date:
8 We recommended that the facility develop and implement a policy that addresses temporary bed locations.
Closure Date:
9 We recommended that the facility revise the computed tomography quality control program to include monitoring by a medical physicist at least annually, image quality monitoring, and computed tomography scanner maintenance.
Closure Date:
10 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
11 We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
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| 15-05164-139 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Maryland Health Care System, Baltimore, Maryland | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Pocomoke City VA Clinic.
Closure Date:
2 We recommended that the clinic manager reviews the Pocomoke City VA Clinic’s hazardous materials inventory twice within a 12-month period.
Closure Date:
3 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
4 We recommended that the Facility Director ensures that the facility’s written policy include the communication of lab results to patients no later than 14 days from the date on which the results are available to the ordering practitioner.
Closure Date:
5 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-05497-132 | Combined Assessment Program Review of the VA Maryland Health Care System, Baltimore, Maryland | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
Closure Date:
2 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
4 We recommended that Environment of Care Committee meeting minutes reflect sufficient discussion of environment of care rounds deficiencies, corrective actions taken to address the deficiencies, and tracking of actions to closure for the three campuses and for the community based outpatient clinics.
Closure Date:
5 We recommended that Acute Care and Non-Acute Care Infection Control Committee meeting minutes consistently reflect discussion of hand hygiene data, actions implemented, and follow-up on actions implemented for the three campuses.
Closure Date:
6 We recommended that facility managers ensure all health care occupancy buildings at the Baltimore and Loch Raven campuses have at least one fire drill per shift per quarter and have documented fire drill critiques and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure the locked mental health unit and public bathrooms on the 3rd, 5th, and 6th floors at the Baltimore campus are frequently and thoroughly cleaned and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms at the Baltimore and Perry Point campuses and monitor compliance.
Closure Date:
9 We recommended that employees at all three campuses promptly remove expired medications from patient care areas and that facility managers monitor compliance.
Closure Date:
10 We recommended that facility managers ensure the Baltimore campus Emergency Department main entrance door is functional and monitor compliance.
Closure Date:
11 We recommended that dental clinic managers ensure all Baltimore campus dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
Closure Date:
12 We recommended that dental clinic managers ensure all Baltimore campus dental clinic employees complete hazard communication training on chemical classification, labeling, and Safety Data Sheets and monitor compliance.
Closure Date:
13 We recommended that dental clinic managers ensure designated Baltimore campus dental clinic employees complete laser safety training and monitor compliance.
Closure Date:
14 We recommended that facility managers ensure operating room housekeepers complete training on cleaning and disinfection procedures.
Closure Date:
15 We recommended that facility managers ensure consistent monitoring of operating room temperature and humidity and monitor compliance.
Closure Date:
16 We recommended that facility managers ensure completion and documentation of periodic surface sampling in the inpatient pharmacy area and monitor compliance.
Closure Date:
17 We recommended that facility managers ensure the airflow monitoring system alarms in the compounded sterile product ante area are functional.
Closure Date:
18 We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
Closure Date:
19 We recommended that facility managers ensure employees perform and document routine cleaning of laminar flow hoods, counters, floors, and storage shelving in the compounding area and monitor compliance.
Closure Date:
20 We recommended that attending physicians consistently document a separate admission note or addendum within 1 day of the patient’s admission.
Closure Date:
21 We recommended that physicians document transfer notes and that facility managers monitor compliance.
Closure Date:
22 We recommended that employees consistently scan the most current advance directive into the electronic health record and that facility managers monitor compliance.
Closure Date:
23 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
24 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
25 We recommended that clinicians include the identification of contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
26 We recommended that clinicians ensure patients and/or family members receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Closure Date:
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| 15-02413-55 | Review of Alleged Wasted Funds in VHA's Southern Arizona VA Health Care System | Audit | ||
1 We recommended the Veterans Integrated Service Network 18 Director ensure the Southern Arizona VA Health Care System develop and implement a policy requiring coordination and review of leased equipment requests with the Health Care System's support services during the acquisition process.
Closure Date:
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| 15-05024-97 | Inspection of the VA Regional Office in Manila, Philippines | Review | ||
1 We recommended the Manila VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
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| 14-03540-123 | Healthcare Inspection – Veterans Crisis Line Caller Response and Quality Assurance Concerns, Canandaigua, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Office of Mental Health Operations Executive Director ensure that issues regarding response hold times when callers are routed to backup crisis centers are addressed and that data is collected, analyzed, tracked, and trended on an ongoing basis to identify system issues.
Closure Date:
2 We recommended that the Office of Mental Health Operations Executive Director ensure that orientation and ongoing training for all Veterans Crisis Line staff is completed and documented.
Closure Date:
3 We recommended that the Office of Mental Health Operations Executive Director ensure that silent monitoring frequency meets the Veterans Crisis Line and American Association of Suicidology requirements and that compliance is monitored.
Closure Date:
4 We recommended that the Office of Mental Health Operations Executive Director establish a formal quality assurance process, as required by the Veterans Health Administration, to identify system issues by collecting, analyzing, tracking, and trending data from the Veterans Crisis Line routing system and backup centers and that subsequent actions are implemented and tracked to resolution.
Closure Date:
5 We recommended that the Office of Mental Health Operations Executive Director consider the development of a Veterans Health Administration directive or handbook for the Veterans Crisis Line.
Closure Date:
6 We recommended that the Office of Mental Health Operations Executive Director ensure that contractual arrangements concerning the Veterans Crisis Line include specific language regarding training compliance, supervision, comprehensiveness of information provided in contact and disposition emails, and quality assurance tasks.
Closure Date:
7 We recommended that the Office of Mental Health Operations Executive Director consider the development of algorithms or progressive situation-specific stepwise processes to provide guidance in the rescue process.
Closure Date:
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| 15-05162-93 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central California VA Health Care System, Fresno, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-05023-112 | Inspection of the VA Regional Office Oakland, California | Review | ||
1 We recommended the Oakland VA Regional Office Director conduct a review of the 58 temporary 100 percent disability evaluations remaining from the inspection universe of 88, and take appropriate action.
Closure Date:
2 We recommended the Oakland VA Regional Office Director implement a plan to ensure all claims processing staff comply with the Veterans Benefits Administration’s second-signature policy for higher levels of special monthly compensation claims.
Closure Date:
3 We recommended that the Acting Under Secretary for Benefits ensure that approved higher levels of special monthly compensation training materials are updated and accurate
Closure Date:
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| 15-05161-98 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Butler Healthcare, Butler, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Cranberry Township VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
Closure Date:
2 We recommended that managers ensure that staff at the Cranberry Township VA Clinic participate in emergency management training and exercises.
Closure Date:
3 We recommended that managers ensure that Cranberry Township VA Clinic employees receive the required hazardous communications training.
Closure Date:
4 We recommended that managers at the Cranberry Township VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
5 We recommended that clinicians complete Home Telehealth enrollment consults.
Closure Date:
6 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
| ||||
| 15-04707-111 | Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility manager’s monitor compliance.
Closure Date:
2 We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
Closure Date:
4 We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, include corrective actions to address those deficiencies, and track corrective actions to closure.
Closure Date:
5 We recommended that Hospital Epidemiology Committee meeting minutes consistently reflect discussion of identified high-risk areas and implementation of actions to address those areas and document follow-up on actions implemented to address identified problems.
Closure Date:
6 We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility revise operating room emergency fire policy and procedures to include alarm activation, evacuation, and equipment shutdown with responsibility for turning off room or zone oxygen.
Closure Date:
8 We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes visual observation/“hands-on” skill assessment of aseptic technique and gloved fingertip sampling.
Closure Date:
9 We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
Closure Date:
10 We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
Closure Date:
11 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
12 We recommended that special care unit sending nurses document transfer assessments and that facility managers monitor compliance.
Closure Date:
13 We recommended physicians consistently document discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
Closure Date:
14 We recommended that facility managers review the organizational alignment for the Radiation Safety Officer position to ensure compliance with Veterans Health Administration policy.
Closure Date:
15 We recommended that facility managers develop and implement a comprehensive computed tomography policy that includes a quality control program and procedures to follow when revising computed tomography protocols.
Closure Date:
16 We recommended that computed tomography technologists perform and document quality control checks, that a supervisory employee conducts periodic review to verify the checks were done, and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
Closure Date:
18 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
Closure Date:
19 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
20 We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
21 We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
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15160