Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-04697-105 | Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming | 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 document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility consistently take actions when data analyses indicate problems or opportunities for improvement and evaluate them for effectiveness in committee reviews, utilization management, and root cause analyses and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility conduct an annual infection prevention risk assessment.
Closure Date:
5 We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
Closure Date:
6 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
7 We recommended that the facility revise its policy for temporary bed locations to include priority placement for inpatient beds given to patients in temporary bed locations, upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
Closure Date:
8 We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
Closure Date:
9 We recommended that clinicians consistently place flags in the electronic health records of patients identified as high risk for suicide and that facility managers monitor compliance.
Closure Date:
10 We recommended that clinicians not place flags in the electronic health records of patients identified as moderate or low risk for suicide and that facility managers monitor compliance.
Closure Date:
11 We recommended that clinicians include the identification of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure electronic health record quality reviews include a representative sample of charts from each service or program.
Closure Date:
13 We recommended that facility managers ensure all non-hospice and palliative care clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
14 We recommended that facility managers establish a process to track and document hospice and palliative care consults that are not acted upon within 7 days of the request.
Closure Date:
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| 15-04708-115 | Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee 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 the Patient Safety Manager submit an annual patient safety report to facility leaders at the completion of each fiscal year.
Closure Date:
5 We recommended that the facility revise its protected peer review policy to be consistent with Veterans Health Administration policy and that facility managers monitor compliance.
Closure Date:
6 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
7 We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Power of Women Embracing Recovery Program have a Class K fire extinguisher available in the kitchen used by residents.
Closure Date:
9 We recommended that Domiciliary Care for Homeless Veterans Program, Post-Traumatic Stress Disorders Residential Rehabilitation Treatment Program, and Substance Abuse Treatment Unit employees consistently perform and document contraband inspections, daily bed checks, and resident room inspections for unsecured medications and that program/unit managers monitor compliance.
Closure Date:
10 We recommended that Domiciliary Care for Homeless Veterans Program and Substance Abuse Treatment Unit managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
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| 15-04696-107 | Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
Closure Date:
2 We recommended that controlled substances inspectors consistently reconcile 1 day's dispensing from the pharmacy to each automated unit and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
3 We recommended that the facility ensure the Controlled Substances Coordinator's position description includes controlled substances oversight duties.
Closure Date:
4 We recommended that the facility ensure controlled substances inspectors receive annual updates and refresher training.
Closure Date:
5 We recommended that the Controlled Substances Coordinator ensure random scheduling of non-pharmacy area inspections with no distinguishable patterns and that facility managers monitor compliance.
Closure Date:
6 We recommended that controlled substances inspectors consistently validate transfers from one storage area to another and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
7 We recommended that controlled substances inspectors consistently verify hard copy orders for five randomly selected dispensing activities (or a minimum of two if less than five dispensing activities on the unit) and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
8 We recommended that pharmacy employees consistently perform 72-hour inventories of the main vault and that facility managers monitor compliance.
Closure Date:
9 We recommended that controlled substances inspectors consistently compare drugs held for destruction with the Destruction File Holding Report for 10 randomly selected drugs and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
10 We recommended that controlled substances inspectors consistently verify completion of drug destructions at least quarterly and that the Controlled Substances Coordinator monitors compliance.
Closure Date:
11 We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
Closure Date:
12 We recommended that clinicians communicate incomplete or probably benign results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
Closure Date:
13 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:
14 We recommended that clinicians include the 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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| 15-05163-106 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Coatesville VA Medical Center, Coatesville, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers provide auditory privacy for Springfield VA Clinic veterans at check-in.
Closure Date:
2 We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
Closure Date:
3 We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-02472-46 | Review of Alleged Untimely Care at VHA’s Community Based Outpatient Clinic Colorado Springs, CO | Audit | ||
1 We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the clinically indicated or preferred appointment dates when scheduling primary care patient appointments.
Closure Date:
2 We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the earliest appropriate date when scheduling new patient appointments.
Closure Date:
3 We recommended the Eastern Colorado Health Care System Director ensure that staff place all veterans with appointments occurring over 30 days after the clinically indicated or preferred appointment date on the Veterans Choice List within 1 day of scheduling the appointment.
Closure Date:
4 We recommended the Eastern Colorado Health Care System Director ensure that resources are sufficient for scheduling staff to act on consults within 7 days and appointment requests for newly enrolled veterans within 1 day of the approved appointment request.
Closure Date:
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| 15-03026-101 | Review of Alleged Patient Scheduling Issues at the VA Medical Center in Tampa, FL | Audit | ||
1 We recommended the Director of James A. Haley Veterans’ Hospital coordinate with the responsible contracting officer to develop a mechanism to ensure the facility receives prompt notification of scheduled Veterans Choice Program appointments.
Closure Date:
2 We recommended the Director of James A. Haley Veterans’ Hospital request that the responsible contracting officer determine if Health Net complies with the modification to the Patient-Centered Community Care contract requiring the contractor to notify VA when a veteran is scheduled for an appointment through the Veterans Choice Program.
Closure Date:
3 We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services transmit all scheduling audit results to appropriate staff for awareness and corrective action.
Closure Date:
4 We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services develop a procedure to verify the schedulers properly correct identified errors.
Closure Date:
5 We recommended the Director of James A. Haley Veterans’ Hospital ensure supervisors provide additional training to schedulers regarding the management of the Veterans Choice List to ensure staff add all eligible veterans to the Veterans Choice List in a timely manner and that veterans remain on the Veterans Choice List.
Closure Date:
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| 15-04983-86 | Inspection of VA Regional Office Little Rock, Arkansas | Review | ||
1 We recommended the Little Rock VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-04706-104 | Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semiannually and that facility managers monitor compliance.
2 We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
3 We recommended that the facility ensure the Women Veterans Program Manager has sufficient allocated administrative time for oversight duties and does not provide direct patient care more than 1/8 of her time (5 hours per week).
4 We recommend that clinicians develop and document Suicide Prevention Safety Plans and that facility managers monitor compliance.
5 We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
6 We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
7 We recommended that domiciliary managers ensure the Domiciliary Care for Homeless Veterans and Substance Abuse Domiciliary has written agreements in place acknowledging resident responsibility for medication security.
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| 15-05155-89 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Western New York Healthcare System, Buffalo, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the Buffalo VA Clinic.
2 We recommended that managers document their consideration and implementation of safety needle devices.
3 We recommended that managers ensure fire drills are conducted at least every 12 months at the Buffalo VA Clinic.
4 We recommended that managers test the alarm system or panic buttons regularly at the Buffalo VA Clinic.
5 We recommended that managers maintain a clean environment of care at the Buffalo VA Clinic.
6 We recommended that managers ensure hand hygiene products are readily accessible to employees at the Buffalo VA Clinic.
7 We recommended that managers provide feminine hygiene products in women’s public restrooms at the Buffalo VA Clinic.
8 We recommended that managers at the Buffalo VA Clinic ensure all medications are secured from unauthorized access.
9 We recommended that managers at the Buffalo VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
10 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
11 We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
12 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
13 We recommended that providers ensure that PTSD patients receive mental health treatment, when applicable.
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| 15-05149-88 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that providers sign home telehealth assessments and treatment plans.
Closure Date:
2 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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15160