Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-04698-99 | Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York | 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.
2 We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
3 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
4 We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
5 We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
6 We recommended that facility managers ensure floors in patient care areas are clean and free of mold and monitor compliance.
7 We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
8 We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes a written test and gloved fingertip sampling.
9 We recommended that the facility fully implement the newly revised compounded sterile products safety/competency assessment checklist that includes all required elements.
10 We recommended that facility managers ensure pharmacy staff remove packaging from items before transfer to the buffer room and clean and sanitize items transferred to the buffer room.
11 We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
12 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.
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| 15-00075-87 | Combined Assessment Program Follow-Up Review of the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure access to exits is unrestricted and monitor compliance.
Closure Date:
2 We recommended that facility managers ensure all nurse call system alarms are functioning and monitor compliance.
Closure Date:
3 We recommended that facility managers ensure emergency response medications and equipment are available for immediate use in patient care areas and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure electrical power strips are not plugged into other power strips and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure crash carts using electrical power strips have those strips permanently attached.
Closure Date:
6 We recommended that facility managers ensure patient care areas do not contain portable space heaters and monitor compliance.
Closure Date:
7 We recommended that the facility repair or replace the uneven and buckling flooring in the combined Domiciliary and Substance Abuse Residential Rehabilitation Treatment Program.
Closure Date:
8 We recommended that facility managers ensure compliance with Safety Data Sheet recommendations regarding chemical storage, use, and safety.
Closure Date:
9 We recommended that facility managers ensure signage identifying the location of alternative exits is posted during construction projects.
Closure Date:
10 We recommended that facility managers ensure signage is installed to clearly identify the location of fire extinguishers in large rooms and those obstructed from view.
Closure Date:
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| 14-05173-92 | Healthcare Inspection – Environment of Care and Safety Concerns in Operating Room Areas, Edward Hines Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Facility Director implement an action plan to remediate water damage in the basement of Building 200.
Closure Date:
2 We recommended that the Acting Facility Director initiate a safety analysis of the current overhead paging and emergency system for communication of a code throughout the entire surgical operating room, including the post anesthesia care units and take action as necessary.
Closure Date:
3 We recommended that the Acting Facility Director implement processes to maintain recommended ranges for temperature and humidity in operating room areas.
Closure Date:
4 We recommended that the Acting Facility Director take actions to prevent staff injury as a result of surgical booms located in operating rooms.
Closure Date:
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| 15-04693-79 | Combined Assessment Program Review of the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, 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 facility managers ensure patient care areas are clean, damaged furniture is repaired or removed from service, and stained ceiling tiles are replaced and monitor compliance.
Closure Date:
4 We recommended that the facility comply with local policy for labeling multi-dose vials with expiration dates after initial use and that facility managers monitor compliance.
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 dental clinic managers ensure all dental clinic employees complete hazard communication training on chemical classification, labeling, and safety data sheets and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure compounded hazardous medications are stored separately from other inventory and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure the emergency eyewash station in the chemotherapy pharmacy has documented weekly testing and monitor compliance.
Closure Date:
9 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
10 We recommended that the facility revise its temporary bed locations policy to include upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
Closure Date:
11 We recommended that clinicians validate patients' and/or caregivers' understanding of the discharge instructions provided.
Closure Date:
12 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:
13 We recommended that the facility complete the required reports regarding patients who attempt or complete suicide and that facility managers monitor compliance.
Closure Date:
14 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:
15 We recommended that the domiciliary teaching kitchen have a Class K fire extinguisher available.
Closure Date:
16 We recommended that domiciliary program managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
17 We recommended that facility managers revise the medication management policy to include securing all medications kept in patient rooms.
Closure Date:
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| 14-04530-41 | Healthcare Inspection – Emergency Department Concerns, Central Alabama VA Health Care System, Montgomery, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Central Alabama Veterans Health Care System Director charter a systems redesign team to improve the timeliness of care delivery in the Emergency Department.
Closure Date:
2 We recommended that the Central Alabama Veterans Health Care System Director revise the Emergency Department triage policy to include reassessment expectations for patients designated as Emergency Severity Index levels 2–5.
Closure Date:
3 We recommended that the Central Alabama Veterans Health Care System Director ensure that adequate staffing is available in the Emergency Department to assure safe special observation to mental health patients.
Closure Date:
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| 15-04694-80 | Combined Assessment Program Review of the Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility implement a consistent Ongoing Professional Practice Evaluation process.
Closure Date:
2 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
3 We recommended that the facility repair damaged furniture in patient care areas or remove it from service and repair damaged walls.
Closure Date:
4 We recommended that the facility repair or replace damaged vinyl floor tiles and heavily soiled, torn, and frayed carpeting in patient care areas.
Closure Date:
5 We recommended that facility managers ensure wheelchairs used by patients and visitors are clean and monitor compliance.
Closure Date:
6 We recommended that facility policy include the frequency of competency assessment requirements for employees who prepare compounded sterile products.
Closure Date:
7 We recommended that pharmacy managers establish compounded sterile products competency assessment requirements for pharmacists.
Closure Date:
8 We recommended that pharmacy managers ensure pharmacy employees who prepare compounded sterile products complete all competency components annually and monitor compliance.
Closure Date:
9 We recommended that the facility revise the compounded sterile products safety/competency assessment checklist to include all required elements.
Closure Date:
10 We recommended that pharmacy managers ensure employees who prepare compounded sterile products don all required personal protective equipment in the ante area prior to entering the IV Prep Room and monitor compliance.
Closure Date:
11 We recommended that pharmacy managers ensure the IV Prep Room has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
Closure Date:
12 We recommended that facility managers ensure employees perform and document daily floor cleaning in the compounding area and monitor compliance.
Closure Date:
13 We recommended that the facility follow up on computed tomography scanners that fail annual inspection by the medical physicist.
Closure Date:
14 We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
Closure Date:
15 We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
Closure Date:
16 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:
17 We recommended that clinicians not place flags in the electronic health records of moderate- and low-risk patients and that facility managers monitor compliance.
Closure Date:
18 We recommended that clinicians include an 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:
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| 15-02217-85 | Healthcare Inspection – Alleged Unsafe Patient Transportation Practices, VA Hudson Valley Health Care System, Montrose, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Director, VA Hudson Valley Health Care System consult with VA NY/NJ Healthcare Network leadership and Regional Counsel regarding the acceptability of shuttle bus drivers’ use of the Passenger Fitness Criteria card.
Closure Date:
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| 15-05151-81 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Chalmers P. Wylie Ambulatory Care Center, Columbus, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers develop and implement a policy that requires the Grove City VA Clinic staff to receive regular information on their responsibilities in emergency response operations.
Closure Date:
2 We recommended that clinicians document verbal informed consent for Home Telehealth services.
Closure Date:
3 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
4 We recommended that the facility director ensure that the facility's written policy for the communication of laboratory results includes all required elements.
Closure Date:
5 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
6 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
Closure Date:
7 We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Closure Date:
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| 14-02465-47 | Audit of VHA’s Non-VA Medical Care Obligations | Audit | ||
1 We recommended that the Under Secretary for Health improve cost estimation tools to ensure adequate Non-VA Care cost estimates are produced consistently.
Closure Date:
2 We recommended that the Under Secretary for Health implement a mechanism to ensure that VA medical facilities perform ongoing reviews and adjust cost estimates for individual authorized services to better reflect actual costs.
Closure Date:
3 We recommended that the Under Secretary for Health update Fee Basis Claims System software to ensure inpatient authorizations can be periodically adjusted when the scope of patient care is fully known.
Closure Date:
4 We recommended that the Under Secretary for Health update Fee Basis Claims System software to allow the system to automatically deobligate unused funds when Non-VA Care staff indicate payments for the authorized services are complete.
Closure Date:
5 We recommended that the Under Secretary for Health implement a mechanism to monitor how effectively VA medical facilities are estimating Non-VA Care obligations.
Closure Date:
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| 15-05148-75 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers test the panic buttons regularly at the Victor J. Saracini VA Outpatient Clinic.
Closure Date:
2 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Victor J. Saracini VA Outpatient Clinic to the parent facility.
Closure Date:
3 We recommended that managers provide feminine hygiene disposal bins in women’s public restrooms at the Victor J. Saracini VA Outpatient Clinic.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
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15160