Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00618-02 | Combined Assessment Program Review of the Alaska VA Healthcare System, Anchorage, Alaska | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director and other key members required by local policy attend Quality Committee meetings or have a delegate represent them.
2 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
3 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
4 We recommended that the facility analyze electronic health record quality data at least quarterly.
5 We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure retrievability, and quality assurance reviews on a sample of the scanned documents.
6 We recommended that the Chief of Staff complete an audit of all licensed independent practitioners’ privileges to ensure they are current and that facility managers monitor compliance.
7 We recommended that facility managers ensure the health care occupancy building has at least one fire drill during administrative hours per quarter and monitor compliance.
8 We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
9 We recommended that the facility revise the tuberculosis prevention plan policy to reflect current status of negative air exchange rooms in the primary care clinic and ensure employees are aware of procedures to care for infectious patients in lieu of negative air exchange rooms.
10 We recommended that facility managers ensure correction of all deficiencies identified during annual physical security surveys.
11 We recommended that controlled substances inspectors consistently complete a physical count of all primary care clinics during the 1st month of each quarter and a physical count of 10 line items for all primary care clinics during the 2nd and 3rd months of each quarter and that the Controlled Substances Coordinator monitors compliance.
12 We recommended that controlled substances inspectors consistently complete pharmacy inspections on the same day initiated and that the Controlled Substances Coordinator monitors compliance.
13 We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
14 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.
15 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.
16 We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
17 We recommended that clinicians ensure all patients assessed to be at high risk for suicide have documented safety plans that specifically address suicidality and that facility managers monitor compliance.
18 We recommended that clinicians ensure that patients and/or their families receive a copy of the safety plan and that facility managers monitor compliance.
19 We recommended that the facility implement an Employee Threat Assessment Team and a centralized disruptive behavior reporting and tracking system.
20 We recommended that facility managers ensure that monthly self-inspection documentation includes safety, security, and privacy.
21 We recommended that the facility Risk Manager continue the recently implemented peer review corrective action tracking process and ensure actions are completed and reported to the Peer Review Committee.
22 We recommended that facility managers consistently initiate Focused Professional Practice Evaluations for newly hired licensed independent practitioners at the time or before they begin providing patient care.
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| 15-00623-18 | Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois | 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 the interdisciplinary committee include a physician to review all episodes of care where resuscitation was attempted.
Closure Date:
3 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
4 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
5 We recommended that the facility develop a computed tomography policy that includes all required elements.
Closure Date:
6 We recommended that a medical physicist inspect computed tomography scanners that have repairs or modifications that affect dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
Closure Date:
7 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:
8 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility revise the electrocardiogram, blood bank, respiratory therapy, and radiology policies to clearly define appropriate availability for support services.
Closure Date:
10 We recommended that facility managers ensure Emergency Department and inpatient medical/surgical unit employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and completed and documented.
Closure Date:
11 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the intensive care unit.
Closure Date:
12 We recommended that facility managers implement a defined plan or policy to have a qualified surgeon available 24/7 on call within 60 minutes.
Closure Date:
13 We recommended that the facility revise the emergency airway management policy to include a plan to manage a difficult airway.
Closure Date:
14 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:
15 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes completion of all required elements at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
Closure Date:
16 We recommended that the facility ensure that a qualified, non-Emergency Department clinician is assigned inpatient emergency airway management coverage and that facility managers monitor compliance.
Closure Date:
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| 14-02890-497 | Healthcare Inspection – Poor Access to Care Allegedly Resulting in a Patient Death at the Oxnard Community Based Outpatient Clinic, VA Greater Los Angeles Healthcare System, Los Angeles, California | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the system provides neurology consults within timeframes required by patients' clinical conditions and current Veterans Health Administration policy.
Closure Date:
2 We recommended that the System Director monitor provider compliance with timeframes for acting on and closing consults in accordance with the current Veterans Health Administration policy.
Closure Date:
3 We recommended that the System Director ensure that providers categorize consults based on urgency and that program managers verify the accuracy of categorizations.
Closure Date:
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| 15-00155-16 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Battle Creek VA Medical Center, Battle Creek, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect and secure specimens and patient-identifiable information at the Muskegon VA Clinic.
Closure Date:
2 We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Muskegon VA Clinic.
Closure Date:
3 We recommended that staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Muskegon VA Clinic.
Closure Date:
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
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.
Closure Date:
6 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
8 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
9 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients 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:
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| 15-00163-01 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure a safe, clean, and well maintained environment of care at the Morristown VA Clinic.
Closure Date:
2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Morristown VA Clinic.
Closure Date:
3 We recommended that all employees at the Morristown VA Clinic receive the required training on hazardous materials.
Closure Date:
4 We recommended that managers ensure that all safety inspections on medical equipment are performed as required by facility policy at the Morristown VA Clinic.
Closure Date:
5 We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Morristown VA Clinic.
Closure Date:
6 We recommended that staff are trained to properly disinfect non-critical medical equipment as required at the Morristown VA Clinic.
Closure Date:
7 We recommended that Morristown VA Clinic staff protect patient-identifiable information on laboratory specimens during transport.
Closure Date:
8 We recommended that the information technology server closet at the Morristown VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
9 We recommended that managers ensure that all staff at the Morristown VA Clinic are trained to safely evacuate using all exit routes from the building.
Closure Date:
10 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
11 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
12 We recommended 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:
13 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
14 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-00177-07 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Marion VA Medical Center, Marion, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that safety data sheets are current at the Paducah VA Clinic.
Closure Date:
2 We recommended that managers ensure staff can access the electronic version of safety data sheets at the Paducah VA Clinic.
Closure Date:
3 We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Paducah VA Clinic in accordance with Joint Commission standards.
Closure Date:
4 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Paducah VA Clinic to the parent facility.
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 Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended 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 notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-00622-06 | Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Cardiopulmonary Resuscitation Subcommittee review each code episode.
Closure Date:
2 We recommended that the Operating Room Management Council meet monthly, include the Chief of Staff and Surgical Quality Nurse as members, and document its review of National Surgical Office reports.
Closure Date:
3 We recommended that the Operating Room Management Council review all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
4 We recommended that the Infection Prevention and Control Sub-Committee document follow-up on actions implemented to address identified problems.
Closure Date:
5 We recommended that facility managers ensure patient care areas are clean and 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 facility managersensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
8 We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
9 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
10 We recommended that radiologists document the radiation dose in the Computerized Patient Record System and that facility managers monitor compliance.
Closure Date:
11 We recommended that employees consistently use appropriate note titles to document advance directive screening and that facility managers monitor compliance.
Closure Date:
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.
Closure Date:
13 We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
Closure Date:
15 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:
16 We recommended that the facility consistently perform continuing stay reviews on at least 75 percent of patients in acute beds.
Closure Date:
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| 14-00875-03 | Healthcare Inspection – Access to Urology Service, Phoenix VA Health Care System, Phoenix, AZ | Hotline Healthcare Inspection | ||
1 We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that resources are in place to deliver timely urological care to patients.
Closure Date:
2 We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that non-VA care providers’ clinical documentation is available in the electronic health records in a timely manner for Phoenix VA Health Care System providers to review.
Closure Date:
3 We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that the cases identified in this report are reviewed, and for patients who suffered adverse outcomes and poor quality of care, confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
Closure Date:
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| 15-00506-535 | Healthcare Inspection – Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Under Secretary for Health perform a quality review of the Chief of Surgery's colonoscopies performed in the prior Veterans Health Administration facility.
Closure Date:
2 We recommended that the Acting Under Secretary for Health revise the Veterans Health Administration Colorectal Cancer Screening directive to include standardized documentation of quality indicators based on professional society guidelines and published literature (including but not limited to photodocumentation of anatomical landmarks establishing cecal intubation and documentation of cecal withdrawal times).
Closure Date:
3 We recommended that the Acting Under Secretary for Health consider adding photodocumentation of cecal intubation and cecal withdrawal time to the standardized criteria for quality colonoscopy for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation.
Closure Date:
4 We recommended that the System Director ensure patient notification of diagnostic test results within the required timeframe, particularly for critical results, and that clinicians document notification.
Closure Date:
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| 15-02053-537 | Review of Alleged Improper Pay at VHA's Hudson Valley Health Care System | Audit | ||
1 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System conducts a review of all Federal Wage Service employees’ official duty stations.
Closure Date:
2 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System takes action to correct any inappropriate Federal Wage Service employees’ official duty stations and wage rates.
Closure Date:
3 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System provides training to all management and Human Resources personnel on how to correctly determine an employee’s official duty station.
Closure Date:
4 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System develops procedures to monitor the accuracy of Federal Wage Service employees’ official duty station.
Closure Date:
5 We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review and consult appropriate VA offices, including the Office of General Counsel, to determine whether administrative action is appropriate for those officials in the Engineering, Environmental Management, and Human Resources Services who did not adequately review or correct employees’ official duty stations in response to the 2014 Office of Human Resources and Administration’s request for verification of all employees’ official duty stations.
Closure Date:
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15160