Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00594-389 | Combined Assessment Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that credentialing and privileging folders do not contain information that is not allowed and monitor compliance.
Closure Date:
2 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
3 We recommended that facility managers ensure nurse call systems with portable telephones have alarms that are audible and monitor compliance.
Closure Date:
4 We recommended that the facility’s Emergency Operations Plan include how the facility manages patient scheduling.
Closure Date:
5 We recommended that facility managers ensure monthly medication storage area inspections are completed on the medical/surgical acute care unit and monitor compliance.
Closure Date:
6 We recommended that facility managers consistently implement corrective actions for issues identified during monthly medication storage area inspections and monitor the changes until issues are fully resolved.
Closure Date:
7 We recommended that facility managers ensure designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
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 facility managers ensure initial clinician emergency airway management competency assessment includes documentation of all required elements.
Closure Date:
10 We recommended that facility managers ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and monitor compliance.
Closure Date:
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| 15-00191-406 | Healthcare Inspection – Alleged Lapse in Timeliness of Care, West Palm Beach VA Medical Center, West Palm Beach, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement procedures to ensure that unstable patients being transported from one area to another in the facility be monitored safely and accompanied by appropriate personnel.
Closure Date:
2 We recommended that the Facility Director ensure that Emergency Department and Interventional Radiology nursing staff receive education on handoff communication requirements.
Closure Date:
3 We recommended that the Facility Director ensure that the facility policy for the handoff communication process be reviewed for inclusion of documentation of handoff communication.
Closure Date:
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| 14-04116-408 | Review of Alleged Delays in Care Caused by Patient-Centered Community Care (PC3) Issues | Audit | ||
1 We recommended the Interim Under Secretary for Health establish timeliness criteria for submitting authorizations to the Patient-Centered Community Care contractors.
Closure Date:
2 We recommended the Interim Under Secretary for Health monitor timeliness of submitting authorizations to Patient-Centered Community Care contractors and take actions to improve timeliness when standards are not met.
Closure Date:
3 We recommended the Interim Under Secretary for Health evaluate the Patient-Centered Community Care contractor networks to ensure they are sufficient to meet contract performance requirements.
Closure Date:
4 We recommended the Interim Under Secretary for Health revise contract terms to eliminate the option of scheduling appointments before communicating with the veteran.
Closure Date:
5 We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors return authorizations if they cannot schedule an appointment within 5 business days of receipt of the authorization.
Closure Date:
6 We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors return authorizations when they cannot arrange for an appointment to take place within 30 days of the appointment creation date.
Closure Date:
7 We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors comply with requirements to notify Veterans Health Administration within 14 days of a missed appointment.
Closure Date:
8 We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors comply with requirements to return medical documentation within 14 days of the appointment's occurrence.
Closure Date:
9 We recommended the Interim Under Secretary for Health implement a mechanism to monitor all authorizations submitted to the Patient-Centered Community Care contractors.
Closure Date:
10 We recommended the Interim Under Secretary for Health revise the Patient-Centered Community Care dashboard to report completed authorizations and the percentage of total authorizations by the specific contractors performing these services.
Closure Date:
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| 15-01116-390 | Healthcare Inspection – Alleged Mental Health Access and Treatment Deficiencies, Brunswick Community Outpatient Clinic, Brunswick, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that clinical staff assign surrogates to manage secure messages as required by Veterans Integrated Service Network 7 policy.
Closure Date:
2 We recommended that the Facility Director ensure that staff comply with Veterans Health Administration policy for scheduling outpatient follow-up appointments, that staff utilize the Recall/Reminder Software application when appropriate, and that compliance be monitored.
Closure Date:
3 We recommended that the Facility Director ensure that community based outpatient clinic staff initiate appropriate follow-up action when a patient is ano show or fails to schedule a follow-up appointment.
Closure Date:
4 We recommended that the Facility Director ensure that services outlined in the treatment plan are provided and that compliance be monitored.
Closure Date:
5 We recommended that the Facility Director ensure processes are in place to ensure continuity of the mental health treatment plan in the event of staff departure and/or reassignment and to discuss proposed changes to treatment plans with patients.
Closure Date:
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| 15-01927-375 | Review of Alleged Mismanagement of Medical Supplies at the VA Medical Center, East Orange, New Jersey | Audit | ||
1 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System purchases and maintains medical supplies at normal stock levels.
Closure Date:
2 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System conducts a 100 percent wall-to-wall inventory of all Medical Supply Distribution Section inventory storage areas and document results.
Closure Date:
3 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System uses the results of the wall-to-wall inventory to assess the accuracy of the Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system, and makes adjustments as deemed appropriate.
Closure Date:
4 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System obtains and mandates the use of one model of barcode scanner to track and maintain medical supply inventory.
Closure Date:
5 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System implements measures to determine reasons discrepancies are occurring in inventories and takes appropriate corrective action before technicians manually adjust the Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system.
Closure Date:
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| 14-01991-387 | Audit of VHA's Homeless Providers Grant and Per Diem Case Management Oversight | Audit | ||
1 We recommended the Interim Under Secretary for Health establish a definitive legal position on Grant and Per Diem Program eligibility.
2 We recommended the Interim Under Secretary for Health revise policies, if necessary, when a definitive legal position is provided on Grant and Per Diem Program eligibility.
3 We recommended the Interim Under Secretary for Health implement controls to ensure grant applications comply with the definitive legal position on Grant and Per Diem Program eligibility.
4 We recommended the Interim Under Secretary for Health assess all medication security controls over controlled and non-controlled substances and conduct additional inspections at funded grantee facilities.
5 We recommended the Interim Under Secretary for Health ensure individually locked medications are safely secured in non-portable storage containers.
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| 15-00601-376 | Combined Assessment Program Review of the North Florida/South GeorgiaVeterans Health System, Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges granted to match their skills and training.
Closure Date:
2 We recommended that the facility reduce credentialing and privileging folders to the two-part format.
Closure Date:
3 We recommended that the Operating Room Committee include the Chief of Staff as a member and that committee minutes reflect review of National Surgical Office reports.
Closure Date:
4 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
Closure Date:
5 We recommended that Infection Control Committee meeting minutes consistently reflect discussion of all identified high-risk areas.
Closure Date:
6 We recommended that facility managers ensure all buildings designated for health care occupancy at the Lake City campus have fire drills conducted once per shift per quarter and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure negative air pressure systems in the Gainesville campus surgical intensive care unit are functional and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure Gainesville campus locked mental health unit stationary panic alarm testing includes documentation of VA Police response time and ensure testing of portable panic alarms and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure designated employees complete competency assessment on the use of emergency evacuation devices and monitor compliance.
Closure Date:
10 We recommended that engineering managers ensure all Gainesville campus construction workers wear VA-issued identification badges and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure that oral syringes are available for liquid medications in all units/areas at the Lake City and Gainesville campuses and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
12 We recommended that employees screen inpatients to determine whether they want to have a discussion about advance directives and document the screening and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
Closure Date:
14 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of a completed written test and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility report provider specific emergency airway management data to the Operative and Invasive Procedures Committee.
Closure Date:
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| 14-04547-401 | Healthcare Inspection – Quality and Coordination of Care Concerns at Two Veterans Integrated Service Network 15 Facilities | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health take steps to prevent prescriptions from being dispensed to deceased veterans.
2 We recommended that the Kansas City VA Medical Center Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
3 We recommended that the Kansas City VA Medical Center Director ensure that processes be strengthened so medication reconciliation is consistently completed and monitor compliance.
4 We recommended that the Kansas City VA Medical Center Director conduct peer reviews of this patient’s care, to include the evaluation and treatment of recurrent falls and the coordination of care.
5 We recommended that the Harry S. Truman Memorial Veterans’ Hospital Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
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| 14-05078-393 | Healthcare Inspection – Credentialing and Privileging Concerns, Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that provider privileges reflect current practice.
Closure Date:
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| 15-01721-382 | Combined Assessment Program Summary Report - Evaluation of Selected Requirements in Veterans Health Administration Community Living Centers | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents who may be candidates for restorative nursing services, the interdisciplinary team documents the reason the resident is not receiving the services or other activities to promote functional status.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents receiving or supposed to receive restorative nursing services, the interdisciplinary team documents goals in their care plans.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that nursing employees provide and document restorative nursing services in accordance with the care plan, and if they do not provide the services, they document the reason.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees complete required restorative summary notes and that the Associate Chief Nurse or designee monitors compliance.
Closure Date:
5 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents not progressing toward restorative goals, the interdisciplinary team reassesses the resident care plan and/or adjusts goals and interventions as necessary.
Closure Date:
6 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that Physical Medicine and Rehabilitation therapists discharging residents from therapy document hand-off communication with nursing employees to ensure interventions continue or are discontinued, as applicable.
Closure Date:
7 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility managers provide and document nursing employee training on range of motion and transfers.
Closure Date:
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15039