Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00595-417 | Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio | 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 facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
Closure Date:
3 We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, that the committee document the screening reviews, and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility include Social Work Service, Chaplain Service, and the Rehabilitation Medicine and Service Care Line in the review of electronic health record quality.
Closure Date:
5 We recommended that facility managers ensure that patient care areas are clean and in good repair and that areas under sinks are not used for storage and monitor compliance.
Closure Date:
6 We recommended that the recently implemented Consult Management Committee continue to meet regularly to review consult data.
Closure Date:
7 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:
8 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 includes all required elements and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure the Domiciliary and Psychosocial Residential Rehabilitation Treatment Programs are clean and monitor compliance.
Closure Date:
10 We recommended that the Domiciliary Residential Rehabilitation Treatment Program have a Class K fire extinguisher available in the kitchen used by residents.
Closure Date:
11 We recommended that the facility correct the deficiencies identified during monthly Domiciliary Residential Rehabilitation Treatment Program self-inspections and that documentation reflects correction.
Closure Date:
12 We recommended that Domiciliary Residential Rehabilitation Treatment Program managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
13 We recommended that clinicians ensure that the safety plans for all patients assessed to be at high risk for suicide specifically address suicidality and that facility managers monitor compliance.
Closure Date:
| ||||
| 14-04037-404 | Healthcare Inspection – Vascular Surgery Resident Supervision, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure the timeframe for supervisor co-signature of inpatient resident progress notes is defined and documented.
Closure Date:
2 We recommended that the System Director ensure that attending surgeons cosign resident progress notes timely.
Closure Date:
| ||||
| 14-04754-407 | Healthcare Inspection – Alleged Colorectal Cancer Screening and Administrative Issues, VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director implement procedures to prevent the unauthorized use of individuals’ signature blocks on form letters.
Closure Date:
| ||||
| 15-01968-424 | Healthcare Inspection – Alleged Poor Quality of Care and Refusal to Pay for Lung Transplantation, Iowa City VA Health Care System, Iowa City, Iowa | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health review how the Veterans Health Administration compensates non-VA facilities for lung transplantation to ensure that reimbursement is appropriate for the services performed.
Closure Date:
2 We recommended that the System Director conduct a focused professional practice evaluation of the care provided by attending physicians at the facility during the patient’s fall 2014 hospitalization.
Closure Date:
| ||||
| 14-04755-428 | Healthcare Inspection – Alleged Dental Service Scheduling and Other Administrative Issues, VA Palo Alto Health Care System, Palo Alto, CA | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director review the dental program after corrective actions have been implemented to ensure that dental care at the system is timely and of high quality.
Closure Date:
2 We recommended that the System Director monitor the dental clinic to ensure that patients receive appropriate access to care, as required by Veterans Health Administration policy.
Closure Date:
3 We recommended that the System Director implement recommendations as described in the 2011 Veterans Health Administration Office of Dentistry Workforce Study regarding staffing in dental clinics.
Closure Date:
4 We recommended that the System Director ensure timely delivery of prosthetic devices and documentation of each step in the process and monitor compliance.
Closure Date:
| ||||
| 14-04401-416 | Healthcare Inspection – Staff and Management Concerns at the Jacksonville Outpatient Clinic, Jacksonville, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director take action to improve the cleanliness and appearance of the carpeted waiting room areas at the Jacksonville Outpatient Clinic.
Closure Date:
| ||||
| 14-04491-394 | Healthcare Inspection – Communication and Quality of Care Concerns, VA Black Hills Health Care System, Fort Meade, SD | Hotline Healthcare Inspection | ||
1 We recommended that the System Director strengthen processes to ensure families or caregivers are notified when patients are transferred to new locations of care.
| ||||
| 14-04049-379 | Healthcare Inspection – Alleged Consult Processing Delay Resulting in Patient Death, VA Eastern Colorado Health Care System, Denver, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the NVCC consult process is clearly defined, the facility has appropriate processes in place to identify and address potential delays, and that compliance is monitored.
| ||||
| 15-01445-400 | Healthcare Inspection – Alleged Short-Stay Rehabilitation Unit Concerns, Tuscaloosa VA Medical Center, Tuscaloosa, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the assessments for patients screened for admission by the facility physiatrist consultant are documented in the electronic health records.
Closure Date:
2 We recommended that the Facility Director ensure Valor Center screening and admission policies are consistent with Valor Center practices.
Closure Date:
3 We recommended that the Facility Director ensure that all relevant staff are notified of planned Valor Center admissions to allow staff sufficient time to make appropriate plans for required care and services.
Closure Date:
| ||||
| 14-04077-405 | Healthcare Inspection – Scheduling, Staffing, and Quality of Care Concerns at the Alaska VA Healthcare System, Anchorage, AK | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement an action plan based on ongoing monitoring of access performance measures that includes recruitment and retention, and ensure continued provision of primary care by a permanent provider at the Mat-Su VA Community Based Outpatient Clinic.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement contingency plans for ensuring patients receive continuity of and access to appropriate primary care during periods of inadequate resources, extended staff absences, staff turnover, understaffing, and nature-related events, as required by Veterans Health Administration policy.
Closure Date:
3 We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement the requirements of Veterans Health Administration Handbook 1101.10, Patient-Aligned Care Teams, regarding care coordination.
Closure Date:
4 We recommended that the Veterans Integrated Service Network Director ensure that the System Director provide access to care at the Mat-Su VA Community Based Outpatient Clinic in accordance with Veterans Health Administration policy and provider recommendations for follow-up.
Closure Date:
5 We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement a peer review process consistent with Veterans Health Administration policy.
Closure Date:
6 We recommended that the Veterans Integrated Service Network Director ensure the System Director perform peer review and consult regional counsel as appropriate for the cases identified in this report.
Closure Date:
7 We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement a provider evaluation process consistent with Veterans Health Administration policy.
Closure Date:
8 We recommended that the Veterans Integrated Service Network Director ensure that the System Director strengthen processes for committee reporting to align with Veterans Health Administration Directive 1026, Enterprise Framework for Quality, Safety, and Value, and system bylaws.
Closure Date:
9 We recommended that the Veterans Integrated Service Network Director ensure that the System Director assess the culture, morale, and leadership issues identified in this report, and take appropriate action as necessary.
Closure Date:
| ||||
15160