Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00179-34 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Southern Nevada Healthcare System, North Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient identifiable information on laboratory specimens during transport from the Southeast VA Clinic to the parent facility or contracted processing facility.
Closure Date:
2 We recommended that panic alarm testing documentation includes specific testing locations at the Southeast VA Clinic.
Closure Date:
3 We recommended that managers at the Southeast VA Clinic maintain attendance records to verify staff participation during emergency management training and exercises.
Closure Date:
4 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
10 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
11 We recommended that clinicians document in the electronic health record all attempts to communicate laboratory results with the patients.
Closure Date:
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| 15-00625-37 | Combined Assessment Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management receive the appropriate training.
Closure Date:
2 We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
Closure Date:
3 We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies and specifics, including the deficiency, location, action, and resolution and any trends.
Closure Date:
4 We recommended that facility managers monitor the use of clean biohazard bags to ensure they are used appropriately.
Closure Date:
5 We recommended that facility managers ensure designated employees receive emergency evacuation device training and competency assessment and revise the local policy to define expectations for competency assessment.
Closure Date:
6 We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
7 We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and on the intensive care-step down unit and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
8 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility revise the local policy to address advance directive notification, screening, and discussions.
Closure Date:
10 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:
11 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:
12 We recommended that Radiology Service revise its policies to require a 30-minute on-call reporting time for computed tomography scans and a 30-minute on-call response time for radiology interpretation.
Closure Date:
13 We recommended that the facility ensure clinicians complete all required emergency airway management competency reassessment elements prior to providing emergency airway management coverage and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility have appropriate emergency airway management coverage during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers ensure that identified deficiencies from the annual pharmacy physical security survey are corrected and monitor compliance.
Closure Date:
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| 15-00624-31 | Combined Assessment Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate training.
Closure Date:
2 We recommended that Intensive Care Unit Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code and that the committee documents the reviews.
Closure Date:
3 We recommended that the Surgical Work Group meet monthly.
Closure Date:
4 We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
Closure Date:
5 We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter.
Closure Date:
6 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:
7 We recommended that facility managers ensure that employees on the medical-surgical and intensive care units and in the Emergency Department have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
8 We recommended that facility managers ensure that intensive care unit employees have post-anesthesia care competency assessment and validation completed and documented.
Closure Date:
9 We recommended that the facility ensure emergency airway management competency is completed at the time of initial privileges and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility ensure clinicians complete all required competency elements prior to the granting or renewal of
privileges or scope of practice and that facility managers monitor compliance.
Closure Date:
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| 15-00142-35 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of John J. Pershing VA Medical Center, Poplar Bluff, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure review of the
hazardous materials inventory occurs twice within a 12-month period at the Pocahontas VA Clinic.
2 We recommended that managers ensure that safety data sheets
are current at the Pocahontas VA Clinic.
3 We recommended that the information technology server closet
at the Pocahontas VA Clinic is maintained according to information technology safety
and security standards.
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
5 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
6 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
9 We recommended that practitioners document a relevant history of the illness or injury and physical findings when the patients are first admitted for VA outpatient care.
10 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
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| 14-03823-19 | Healthcare Inspection – Access and Oversight Concerns for Home Health Services, Washington DC VA Medical Center, Washington, District of Columbia | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health require facilities to developaction plans to address the care needs of patients on home health services electronic wait lists.
Closure Date:
2 We recommended that the Facility Director ensure that staff comply with all elementsof national and local policies regarding quality of care, communication, and documentation related to purchased home and community based services.
Closure Date:
3 We recommended that the Facility Director ensure that oversight and managementof purchased home and community based services is adequate and in compliance with Veterans Health Administration policies.
Closure Date:
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| 14-04756-32 | Audit of the Seismic Safety of VA’s Facilities | Audit | ||
1 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction establish policy requiring medical facilities to conduct detailed seismic studies for all critical and essential buildings located in high and very high seismic zones that have not already undergone detailed seismic studies.
Closure Date:
2 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to require Facility Condition Assessment contractors to review structural design documents for buildings that have completed seismic retrofit projects.
Closure Date:
3 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to ensure conditions of seismically unsafe buildings are properly reported on assessment reports.
Closure Date:
4 We recommended the Under Secretary for Health ensure medical facilities submit construction project applications, in a timely manner, for all identified seismically unsafe structural and nonstructural deficiencies.
Closure Date:
5 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure that Facility Condition Assessment contractors include specific and detailed descriptions of nonstructural seismic deficiencies in their assessments.
Closure Date:
6 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
Closure Date:
7 We recommended the Under Secretary for Health ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
Closure Date:
8 We recommended the Acting Assistant Secretary for Management revise VA Directive 7415 to mandate that enhanced use lease agreements require developers to certify the seismic safety of buildings or to have a plan for mitigating identified seismic deficiencies prior to renewal or execution of new facility use agreements with VA organizations.
Closure Date:
9 We recommended the Under Secretary for Health develop policies and procedures requiring VHA medical facilities to develop and test Continuity of Operations Plans, to include documenting the testing performed, in accordance with Federal Continuity Directive 1 requirements.
Closure Date:
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| 15-00621-23 | Combined Assessment Program Review of the Charles George VA Medical Center,Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
Closure Date:
2 We recommended that the Surgical Work Group meet monthly.
Closure Date:
3 We recommended that the facility include most services in the review of electronic health record quality.
Closure Date:
4 We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure negative air pressure systems on the surgical intensive care unit are functional and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure that locked mental health unit stationary and portable panic alarm testing includes documentation of VA Police response times.
Closure Date:
7 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
8 We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the corrective actions until fully resolved.
Closure Date:
9 We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for nursing employee users and that facility managers monitor compliance.
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 employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
12 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility revise the local policy to include that all designated non-anesthesia providers receive training in emergency airway management.
Closure Date:
14 We recommended that the facility complete a root cause analysis for the event to determine why this vulnerability existed and initiate appropriate system improvements.
Closure Date:
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| 15-00626-28 | Combined Assessment Program Review of the VA Pacific Islands Health Care System, Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
Closure Date:
2 We recommended that Environment of Care Committee meeting minutes consistently document tracking of identified deficiencies to closure and that monthly meetings consistently include community based outpatient clinic representation.
Closure Date:
3 We recommended that Infection Control Committee meeting minutes consistently reflect discussion of identified high-risk areas.
Closure Date:
4 We recommended that facility managers ensure furnishings and equipment in patient care areas are in good repair and have upholstery that is easily cleaned.
Closure Date:
5 We recommended that facility managers ensure employees routinely inspect Center for Aging privacy and shower curtains and initiate actions to replace those with stains.
Closure Date:
6 We recommended that facility managers ensure heavy-use public restrooms in the ambulatory care center have frequent inspections and receive cleaning as needed.
Closure Date:
7 We recommended that facility managers initiate corrective actions to repair the ceiling leak in the ambulatory care center.
Closure Date:
8 We recommended that employees store clean and dirty items separately and promptly remove cardboard boxes from storage areas and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure negative air pressure systems are functional in all designated rooms and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure all chairs in the acute psychiatry unit 3B2 dining/activity room are weighted.
Closure Date:
11 We recommended that the facility’s Emergency Operations Plan include all required Joint Commission elements.
Closure Date:
12 We recommended that the facility implement an adequate back-up plan for a Suicide Prevention Coordinator.
Closure Date:
13 We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and for identifying and tracking patients who are at high risk for suicide
Closure Date:
14 We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility implement a process to follow up on patients who miss MH appointments and that facility managers monitor compliance.
Closure Date:
16 We recommended that clinicians include patients and/or their families in safety plan development and that facility managers monitor compliance.
Closure Date:
17 We recommended that mental health providers ensure outpatients flagged as high risk for suicide have a suicide prevention safety plan completed within the first 72 hours of contact and that facility managers monitor compliance.
Closure Date:
18 We recommended that mental health providers ensure outpatients flagged as high risk for suicide are evaluated at least four times within 30 days of flag placement if an outpatient or at least four times within 30 days of discharge from the inpatient psychiatric unit and that facility managers monitor compliance.
Closure Date:
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| 15-00600-33 | Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
Closure Date:
2 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the privileges to do so.
Closure Date:
3 We recommended that facility managers ensure emergency airway management privileges for licensed independent practitioners are reviewed, signed, and dated prior to granting the privileges.
Closure Date:
4 We recommended that the Cardiopulmonary Resuscitation Committee review all episodes of care where resuscitation was attempted.
Closure Date:
5 We recommended that the facility ensure the recently established Safe Patient Handling Committee continues to meet and provide oversight of the safe patient handling program.
Closure Date:
6 We recommended that facility managers ensure all sharps containers are sealed tightly at the point of collection and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure evacuation devices are immediately accessible in patient care areas and monitor compliance.
Closure Date:
8 We recommended that for all construction projects, the facility initiate Interim Life Safety Measures as required and post any needed alternative exit signage and that facility managers monitor compliance.
Closure Date:
9 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
10 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
11 We recommended that the facility revise the computed tomography policy to include a quality control program.
Closure Date:
12 We recommended that the facility revise the emergency airway management policy to include a plan to manage a difficult airway.
Closure Date:
13 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers strengthen processes to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and in instances of occurrence, initiate root cause analyses.
Closure Date:
16 We recommended that the facility ensure all home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order and that facility managers monitor compliance.
Closure Date:
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| 15-00187-25 | Healthcare Inspection – Alleged Program Inefficiencies and Delayed Care, Veterans Health Administration’s National Transplant Program | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health review the extent of delays in responses to referrals for transplant evaluations; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely responses to referrals for liver transplant evaluations.
Closure Date:
2 We recommended that the Under Secretary for Health review the extent of delays in initial patient evaluations for transplantation; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely initial patient evaluations.
Closure Date:
3 We recommended that, after reviewing the circumstances of delays in responses to referrals and initial patient evaluations for transplantation, the Under Secretary for Health take action to confirm that any patients who experienced delayed care that presented risks received appropriate care.
Closure Date:
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15160