Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-04876-204 | Inspection of VA Regional Office Indianapolis, Indiana | Review | ||
1 We recommended the Indianapolis VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications to request medical reexaminations.
Closure Date:
2 We recommended the Indianapolis VA Regional Office Director conduct a review of the 353 temporary 100 percent disability evaluations remaining from their inspection universe as of September 2, 2014, and take appropriate action.
Closure Date:
3 We recommended the Indianapolis VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for Special Monthly Compensation and ancillary benefits.
Closure Date:
4 We recommended the Indianapolis VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-00075-351 | Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director continue to chair Quality Executive Board meetings.
Closure Date:
2 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 prior to the final level assignment.
Closure Date:
3 We recommended that the Medical Executive Board and the Facility Director consistently review and approve all privilege forms annually and all revised privilege forms and document the review.
Closure Date:
4 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have properly approved/signed privilege forms.
Closure Date:
5 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
Closure Date:
6 We recommended that the facility implement a policy that defines Surgical Work Group membership.
Closure Date:
7 We recommended that the Surgical Work Group document its review of National Surgical Office reports and its review of all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
8 We recommended that clinicians report all critical incidents through the facility’s adverse event reporting process.
Closure Date:
9 We recommended that the facility review the quality of entries in the electronic health record and analyze data at least quarterly.
Closure Date:
10 We recommended that the facility fully implement the new quality control policy for scanning and that facility managers monitor compliance.
Closure Date:
11 We recommended that Environment of Care Committee minutes include discussion regarding environment of care rounds deficiencies and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
Closure Date:
13 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
14 We recommended that the facility store oxygen tanks in a manner that distinguishes between empty and full tanks and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers ensure all electrical gang boxes have the appropriate covers installed.
Closure Date:
16 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility promptly remove outdated commercial supplies from sterile supply rooms and that facility managers monitor compliance.
Closure Date:
18 We recommended that the facility promptly remove expired medications from patient care areas and that facility managers monitor compliance.
Closure Date:
19 We recommended that the facility label medications in accordance with local policy and that facility managers monitor compliance.
Closure Date:
20 We recommended that the facility inspect alarm-equipped medical devices according to local policy and the manufacturers’ recommendations and that facility managers monitor compliance.
Closure Date:
21 We recommended that the facility document functionality checks of the community living center’s elopement prevention system at least every 24 hours and conduct and document annual complete system checks and that facility managers monitor compliance.
Closure Date:
22 We recommended that the facility inspect and tag critical medical equipment in the community living center and that facility managers monitor compliance.
Closure Date:
23 We recommended that facility managers ensure crash cart logs contain the correct lock numbers and monitor compliance.
Closure Date:
24 We recommended that the facility ensure the look-alike and sound-alike medication list is available for staff reference in all areas.
Closure Date:
25 We recommended that the facility ensure the high-alert medication list is available for staff reference.
Closure Date:
26 We recommended that the facility create/designate a committee to oversee consult management.
Closure Date:
27 We recommended that the Medicine, Mental Health, Surgical, and Rehabilitation Services’ Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
Closure Date:
28 We recommended that Medicine, Mental Health, Surgical, and Rehabilitation Services designate an individual to review and manage consults.
Closure Date:
29 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
30 We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
31 We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
Closure Date:
32 We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
33 We recommended that the facility ensure all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
34 We recommended that the facility revise the stroke policy to address a stroke team and data gathering for analysis and improvement and that facility managers fully implement the revised policy.
Closure Date:
35 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
Closure Date:
36 We recommended that the facility collect and report to the Veterans Health Administration the percent of patients with stroke symptoms who had the stroke scale completed and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
37 We recommended that Radiology Service revise the computed tomography scan, magnetic resonance imaging/magnetic resonance angiograms, and radiology interpretation on-call policy to require a 30-minute reporting time.
Closure Date:
38 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:
39 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:
40 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:
41 We recommended that the facility ensure that clinicians reassessed for continued emergency airway management have a statement related to emergency airway management included in an approved scope of practice.
Closure Date:
42 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:
43 We recommended that facility managers strengthen processes to minimize a repeat occurrence in which non-privileged providers perform intubations and in instances of occurrence, initiate root cause analyses.
Closure Date:
44 We recommended that facility managers ensure that only authorized patients, staff, and visitors access the Domiciliary Residential Rehabilitation Treatment Program.
Closure Date:
45 We recommended that facility managers ensure that the Domiciliary Residential Rehabilitation Treatment Program does not have closed circuit television in treatment areas.
Closure Date:
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| 15-00076-350 | Combined Assessment Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Accident Review Board gather, track and share patient handling injury data.
Closure Date:
2 We recommended that the facility include most services and program areas in the review of electronic health record quality.
Closure Date:
3 We recommended that the facility institute unique refrigerator bin storage practices for look-alike and sound-alike medications in all areas and that facility managers monitor compliance.
Closure Date:
4 We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
Closure Date:
5 We recommended that clinicians complete and document National Institutes of Health stroke scales for each patient and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and completion of a written test and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
Closure Date:
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| 15-00112-338 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Puget Sound Health Care System, Seattle, Washington | 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 North Olympic Peninsula CBOC.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 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:
4 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:
5 We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
Closure Date:
6 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 15-00126-342 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Boston Healthcare System, Boston, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Causeway VA Clinic to the parent facility.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that clinic staff consistently document the offer
of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
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:
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| 14-03380-356 | FY 2014 Review of VA’s Compliance With the Improper Payments Elimination and Recovery Act | Audit | ||
1 We recommended the Interim Under Secretary for Health ensure implementation of the revised sampling plan for the Civilian Health and Medical Program of the Department of Veterans Affairs to address sample outliers and adjust the program¿s reduction target to a reasonably achievable level, if necessary.
Closure Date:
2 We recommended the Under Secretary for Benefits monitor the results of the Veterans Benefits Administration¿s revised testing plans for the Compensation, Pension, Montgomery G.I. Bill, and Vocational Rehabilitation and Employment programs and adjust the reduction targets to reasonably achievable levels, if necessary.
Closure Date:
3 We recommended the Under Secretary for Benefits implement revised testing plans for the Post-9/11 G.I. Bill and its other reported Education programs that ensure valid and auditable estimates of improper payments.
Closure Date:
4 We recommended that the Acting Assistant Secretary for Management improve the risk assessment guidance and instructions to include an assessment of risk associated with contracting activities.
Closure Date:
5 We recommended that the Acting Assistant Secretary for Management perform risk assessments for programs with a high concentration of vendor payments using revised procedures that include contracting risk.
Closure Date:
6 We recommended that the Under Secretary for Benefits ensure thorough testing of sample items used to estimate improper payments for the Compensation program.
Closure Date:
7 We recommended that the Under Secretary for Benefits consult with the Office of Management and Budget regarding the potential designation of the Compensation program as a high-priority program.
Closure Date:
8 We recommended that the Under Secretary for Benefits use the annual Department of Defense drill pay matching file to identify improper drill pay-related payments in its Compensation and Pension program samples to ensure accurate and auditable reporting.
Closure Date:
9 We recommended that the Interim Under Secretary for Health improve test procedures for the Non-VA Medical Care and Purchased Long Term Services and Support programs by verifying the existence of valid contracts that support payments for these programs.
Closure Date:
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| 15-00124-227 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months
at the O’Neill VA Clinic.
2 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
3 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.
4 We recommended that the Facility Director develops policies and
procedures that facilitate human immunodeficiency virus testing as part of routine
medical care for patients.
5 We recommended that clinicians provide human
immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
| ||||
| 15-00110-228 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Palo Alto Health Care System, Palo Alto, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Fremont CBOC receive the required training on hazardous materials.
Closure Date:
2 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Fremont CBOC to the parent facility.
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 Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 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:
6 We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
| ||||
| 15-00129-339 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Roseburg Healthcare System, Roseburg, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Brookings CBOC in accordance with Joint Commission standards.
Closure Date:
2 We recommended that managers monitor hand hygiene compliance at the Brookings CBOC and report compliance levels to the Infection Control Committee.
Closure Date:
3 We recommended that the information technology staff maintain the information technology server closet at the Brookings CBOC according to information technology safety and security standards.
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 clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coach training as required.
Closure Date:
8 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-04493-198 | Review of Alleged Mismanagement of Radiologists Interpretations at Central Arkansas Veterans Healthcare System | Audit | ||
1 We recommended the Interim Veterans Integrated Service Network 16 Director review TalkStation data showing the time interpretations started and ended to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
Closure Date:
2 We recommended the Interim Veterans Integrated Service Network 16 Director require the Central Arkansas Veterans Healthcare System to establish policy on an official tour of duty for weekends to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
Closure Date:
3 We recommended the Interim Veterans Integrated Service Network 16 Director annually review the Teleradiology Reading Center agreement and certify that services are still needed, qualified individuals in the specialty are not available locally, and other business options have been considered for obtaining services.
Closure Date:
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15160