Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00605-544 | Combined Assessment Program Review of the VA Maine Healthcare System, Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director chair or co-chair the Performance Improvement Board.
Closure Date:
2 We recommended that facility managers review privilege forms annually and document the review.
Closure Date:
3 We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassess observation criteria and utilization.
Closure Date:
4 We recommended that the Special Care Unit Committee review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
5 We recommended that the facility consistently include most services in the review of electronic health record quality.
Closure Date:
6 We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, a complete review of scanned documents to ensure readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
Closure Date:
7 We recommended that facility managers ensure patient care areas are clean and damaged wall surfaces are repaired and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure the walkway from the handicapped parking area to the main entrance is repaired.
Closure Date:
9 We recommended that employees promptly remove expired or undated medications from patient care areas and that facility managers monitor compliance.
Closure Date:
10 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
11 We recommended that the facility develop a written policy for safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
Closure Date:
12 We recommended that the facility create/designate a committee to oversee consult management.
Closure Date:
13 We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
Closure Date:
14 We recommended that employees consistently correctly post patients' advance directives status and that facility managers monitor compliance.
Closure Date:
15 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
16 We recommended that facility managers ensure that special care unit nurses have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
17 We recommended that the facility revise the emergency airway management policy to include the availability of portable video laryngoscopes, the use of a device to confirm endotracheal tube placement in conjunction with auscultation, and a plan for managing the difficult airway.
Closure Date:
18 We recommended that facility managers ensure completion of initial assessments for emergency airway management competency prior to the clinicians providing coverage.
Closure Date:
19 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
Closure Date:
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| 15-00617-539 | Combined Assessment Program Review of theWilliam S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
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| 15-00574-501 | Review of Patient-Centered Community Care (PC3) Health Record Coordination | Audit | ||
1 We recommended the Under Secretary for Health implement a mechanism to ensure payments are not made to Patient-Centered Community Care contractors until all required clinical documentation is received.
Closure Date:
2 We recommended the Under Secretary for Health enforce Patient-Centered Community Care contract performance requirements to ensure that contractors return complete clinical documentation timely.
Closure Date:
3 We recommended the Under Secretary for Health implement a mechanism to verify contractors¿ performance without relying on contractors¿ self-reported data.
Closure Date:
4 We recommended the Under Secretary for Health complete a review of TriWest's performance and apply penalties if it is determined there is a lack of performance related to the timely return of clinical documentation.
Closure Date:
5 We recommended the Under Secretary for Health review the contract disincentives applied to HealthNet and determine if additional funds need to be recouped from the contractor and pursue collection if disincentives were under applied.
Closure Date:
6 We recommended the Under Secretary for Health ensure that Patient-Centered Community Care contractors annotate on all diagnostic imaging reports and non-imaging-related critical findings submitted to VA the name of the VA person contacted, and the date and time of the contact.
Closure Date:
7 We recommended the Under Secretary for Health implement procedures to verify whether Patient-Centered Community Care contractors and their network providers correctly and timely report critical findings to VA and impose financial penalties or other remedies when contractors fall below the contract performance threshold.
Closure Date:
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| 15-00616-543 | Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee.
Closure Date:
2 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management are granted privileges to perform the procedure.
Closure Date:
3 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
Closure Date:
4 We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies and include corrective actions and tracking of actions to closure.
Closure Date:
5 We recommended that facility managers ensure employees initiate corrective actions when sterile supply room temperature and/or humidity values are out of range and monitor compliance.
Closure Date:
6 We recommended that the facility repair or replace damaged paper towel dispensers in patient and public restrooms and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility repair damaged patient equipment and furnishings or remove them from service and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure crash cart logs contain the correct lock number and monitor compliance.
Closure Date:
10 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
11 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
12 We recommended that employees follow up with inpatients who would like to discuss creating, changing, and/or revoking advance directives to ensure the discussion takes place and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements 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 all required competency elements prior to being assigned coverage.
Closure Date:
15 We recommended that facility managers ensure video laryngoscopes are available in all designated locations at the Lyons campus and monitor compliance.
Closure Date:
16 We recommended that facility managers ensure that the Domiciliary Care for Homeless Veterans Program has signage alerting veterans and visitors of closed circuit television recording.
Closure Date:
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| 14-03434-530 | Review of Allegations of Inappropriately Completed Consults and Inappropriate Bonuses at the St. Louis VA Health Care System | Audit | ||
1 We recommended the Director of the St. Louis VA Health Care System ensure scheduling staff receive appropriate training and guidance on proper consult management.
Closure Date:
2 We recommended the Director of the St. Louis VA Health Care System perform a follow-up analysis and regular oversight of completed consults to ensure consults are not designated as “Complete” before the provider sees the patient.
Closure Date:
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| 15-00718-507 | Review of VHA's Patient-Centered Community Care (PC3) Provider Network Adequacy | Audit | ||
1 We recommended the Under Secretary for Health ensure the establishment of an adequate governance structure to oversee and improve Patient-Centered Community Care management and operations.
Closure Date:
2 We recommended the Under Secretary for Health ensure adequate implementation and performance monitoring plans are developed for future high-dollar, complex health care initiatives.
Closure Date:
3 We recommended the Under Secretary for Health assess where Patient-Centered Community Care provider networks are inadequate and develop action plans to improve provider networks that are unable to provide health care services at the specific geographic locations identified.
Closure Date:
4 We recommended the Under Secretary for Health ensure the Patient-Centered Community Care Quality Assurance Surveillance Plan is revised to address the monitoring and measurement of network adequacy.
Closure Date:
5 We recommended the Under Secretary for Health require the input of National Provider Identifier information for rendering providers in the Fee Basis Claims System to ensure adequate data are available for program evaluation and planning.
Closure Date:
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| 14-02952-498 | Healthcare Inspection – Quality of Care Concerns in a Diagnostic Evaluation, Jesse Brown VA Medical Center, Chicago, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director evaluate the scheduling process for vascular consultations and diagnostic tests and take action if factors potentially impacting quality of care are identified.
2 We recommended that the Facility Director evaluate the practice of vascular laboratory technicians interpreting the urgency of providers’ consult requests and whether providers are notified when consult requests are not scheduled within the providers’ timeframe and take action if needed.
3 We recommended that the Facility Director develop a policy defining who is responsible for provider and patient notification of consults ordered through the Emergency Department or Urgent Care Clinic that are not completed timely according to Veterans Health Administration policy.
4 We recommended that the Facility Director ensure that providers perform comprehensive pain assessments according to Veterans Health Administration policy and monitor compliance.
5 We recommended that the Facility Director conduct an internal evaluation of the case discussed in this report.
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| 14-04945-413 | Review of Alleged Data Sharing Violations at VA's Palo Alto Health Care System | Audit | ||
1 We recommended the VA Assistant Secretary for Information and Technology take action to ensure the Palo Alto Health Care System Information Security Officers conduct a risk assessment of Kyron software to identify potential risks, vulnerabilities, and threats to VA systems and sensitive information.
Closure Date:
2 We recommended the VA Assistant Secretary for Information and Technology implement appropriate controls to ensure that unauthorized software is not procured or installed on VA networks without a formal risk assessment and approval to operate.
Closure Date:
3 We recommended the Palo Alto Health Care System Management, in conjunction with VA’s Assistant Secretary for Information and Technology, ensure Kyron personnel receive commensurate background investigations and obtain formal authorization to operate Kyron software on VA networks.
Closure Date:
4 We recommended the Palo Alto Health Care System Management, in conjunction with VA’s Assistant Secretary for Information and Technology, require Kyron personnel to complete security awareness training and sign the Contractor Rules of Behavior to ensure full awareness of VA information security requirements when accessing VA systems and networks.
Closure Date:
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| 15-00165-529 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of William S. Middleton Memorial Veterans Hospital, Madison, WI | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Baraboo VA Clinic.
Closure Date:
2 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that the Acting Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
7 We recommended that the Acting Facility Director ensures that the facility's written policy for the communication of laboratory results included all required elements.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
9 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
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| 15-00166-531 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Alaska VA Healthcare System, Anchorage, Alaska | 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 Fairbanks CBOC.
Closure Date:
2 We recommended that staff store clean supplies separate from infectious materials at the Fairbanks CBOC.
Closure Date:
3 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that providers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
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 the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
Closure Date:
11 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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15303