Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-03824-155 | Healthcare Inspection – Lapses in Access and Quality of Care, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that patient aligned care team provider staffing is adequate to provide patients with timely access to care.
Closure Date:
2 We recommended that the System Director ensure that a contingency plan for patient aligned care team provider shortages is developed.
Closure Date:
3 We recommended that the System Director ensure that patient aligned care team cancellations and other data are monitored to determine when there is a need to activate a contingency plan.
Closure Date:
4 We recommended that the System Director ensure that staff comply with local and national policies on contacting patients when scheduling mental health services.
Closure Date:
5 We recommended that the System Director ensure that policy requirements for discontinuation of mental health consultation are clear and that staff comply with those requirements.
Closure Date:
6 We recommended that the System Director ensure that the Access Action Plan for Orthopedic Surgery Services is carried out in an effort to improve access to orthopedic surgical services.
Closure Date:
7 We recommended that the System Director ensure that providers comply with their responsibilities of electronic health record documentation of the community care of co-managed patients.
Closure Date:
8 We recommended that the System Director ensure compliance with local policy requiring that community health care records be scanned into the electronic health records of co-managed patients.
Closure Date:
9 We recommended that the System Director ensure that the local outpatient tube-feeding policy and practice comply with Veterans Health Administration requirements.
Closure Date:
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| 13-01730-159 | Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff (COS) confer with the Offices of Human Resources (OHR), General Counsel (OGC), and Accountability Review (OAR) to determine the appropriate administrative action to take, if any, against the OIT employees involved in this particular matter.
Closure Date:
2 We recommend that the COS confer with OGC and the Executive Director of the Office of Acquisition Operations (OAO) to determine the appropriate action to take against Systems Made Simple, Inc., for contractor employees failing to adhere to VA information security policies and contract security requirements.
Closure Date:
3 We recommend that the COS ensure that VA's information security policies are thoroughly reviewed and rewritten to address any weaknesses.
Closure Date:
4 We recommend that the COS ensure that VA's information security training is thoroughly reviewed and rewritten to address any weaknesses.
Closure Date:
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| 15-00073-200 | Combined Assessment Program Review of the Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Special Care Unit Committee review each code episode.
2 We recommended that the Surgical Quality Council meet monthly and document its review of National Surgical Office reports.
3 We recommended that the Surgical Quality Council review all surgical deaths with identified problems or opportunities for improvement.
4 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
5 We recommended that the facility use special medication labeling and unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
6 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
7 We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
8 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users and that facility managers monitor compliance.
9 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.
10 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
11 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
12 We recommended that facility managers revise local policies to require that radiology interpretation and computerized tomography coverage be available on call within 30 minutes.
13 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
14 We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.
15 We recommended that facility managers ensure that monthly inspections of the Mental Health Residential Rehabilitation Treatment Programs include all required elements.
16 We recommended that Mental Health Residential Rehabilitation Treatment Program managers ensure that the programs have written agreements in place acknowledging resident responsibility for medication security.
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| 15-00069-199 | Combined Assessment Program Review of the VA Puget Sound Health Care System, Seattle, Washington | 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 prior to the final level assignment.
Closure Date:
2 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:
3 We recommended that the Surgical Work Group include the Chief of Staff as a member.
Closure Date:
4 We recommended that the Safe Patient Handling Committee track patient handling injury data.
Closure Date:
5 We recommended the facility ensure a third party conducts quality assurance reviews on a sample of the scanned documents.
Closure Date:
6 We recommended that Environment of Care Board and Safety Committee minutes include corrective actions to address identified deficiencies and track those actions to closure.
Closure Date:
7 We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure community living center treatment carts containing resident care supplies are clean and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure critical medical equipment in the community living center is plugged into outlets that function in the event of a power loss and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
Closure Date:
11 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
13 We recommended that nursing reviewers sign the monthly medication review forms and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility’s recently chartered Consult Management Committee meet regularly and document oversight of consult management.
Closure Date:
15 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
16 We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
18 We recommended that Level 2 magnetic resonance imaging personnel review and sign secondary patient safety screening forms prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
19 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:
20 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:
21 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
22 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:
23 We recommended that facility managers ensure the American Lake division follows local emergency airway management policy, or if the facility plans to perform intubations in areas designated to call 911, the facility updates the local emergency airway management policy and ensures privileged providers or clinicians with emergency airway management scope of practice are available.
Closure Date:
24 We recommended that facility managers ensure reporting of emergency airway management data to the designated committee with the frequency required by local policy.
Closure Date:
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| 15-00072-160 | Combined Assessment Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Environment of Care Committee gather, track, and share patient handling injury data.
Closure Date:
2 We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers 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 conduct contrast reaction drills in magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
6 We recommended that the facility ensure all designated Level 1 ancillary staff and 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:
7 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:
8 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
9 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
10 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:
11 We recommended that the facility collect and report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, 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:
12 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 mangers monitor compliance.
Closure Date:
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| 15-00071-158 | Combined Assessment Program Review of the West Palm Beach VA Medical Center, West Palm Beach, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that emergency airway management privileges granted are appropriate for the practitioners' skills and training.
Closure Date:
2 We recommended that the Cardiopulmonary Resuscitation 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:
3 We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document did not meet image quality controls and a correction process if scanned items have errors.
Closure Date:
4 We recommended that Environment of Care Committee minutes include consistent discussion of rounds deficiencies, trends, and actions and tracking of actions to closure.
Closure Date:
5 We recommended that infection prevention and control meeting minutes consistently reflect discussion of identified high-risk priority areas.
Closure Date:
6 We recommended that facility managers ensure patient care areas and public restrooms are clean and toilet paper dispensers are in good repair and monitor compliance.
Closure Date:
7 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility secure medication carts when not in use and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
10 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
12 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility update the local consult policy for policy changes and review the policy at least every 3 years and that facility managers monitor compliance.
Closure Date:
14 We recommended that the facility conduct contrast reaction and fire emergency drills in magnetic resonance imaging and that the facility managers monitor compliance.
Closure Date:
15 We recommended that the facility conduct initial patient safety screenings and that the facility managers monitor compliance.
Closure Date:
16 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 the facility managers monitor compliance.
Closure Date:
17 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:
18 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
19 We recommended that the facility report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, 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:
20 We recommended that facility managers ensure that all nursing employees who perform 12-lead electrocardiograms have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and have 12-lead electrocardiogram competency assessment and validation completed and documented.
Closure Date:
21 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the 2B-ICU.
Closure Date:
22 We recommended that the facility revise the emergency airway management policy to include a specific plan to manage difficult airways.
Closure Date:
23 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements, including a written test, and that facility managers monitor compliance.
Closure Date:
24 We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Closure Date:
25 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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| 14-03927-197 | Healthcare Inspection – Patient Telemetry Monitoring Concerns, Michael E. DeBakey VA Medical Center, Houston, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the appropriateness of assigning patients to telemetry is reviewed.
Closure Date:
2 We recommended that the Facility Director ensure dedicated wireless telephones are continuously carried by unit charge nurses or designees for effective communication between unit and telemetry monitoring technicians as required by local policy.
Closure Date:
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| 15-00108-194 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Martinsburg VA Medical Center, Martinsburg, West Virginia | 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 Fort Detrick CBOC.
Closure Date:
2 We recommended that employees at the Fort Detrick CBOC receive the required training on hazardous materials.
Closure Date:
3 We recommended that personal protective equipment is available for all staff at the Fort Detrick CBOC.
Closure Date:
4 We recommended that staff protect patient-identifiable information on laboratory specimens at the Fort Detrick CBOC.
Closure Date:
5 We recommended that the information technology server closet at the Fort Detrick CBOC is maintained according to information technology safety and security standards.
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 receive motivational interviewing and health coaching training within the time frame specified in VHA policy.
Closure Date:
8 We recommended that all providers and clinical associates in the outpatient clinics receive health coaching training within the time frame specified in VHA policy.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-04391-162 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Ann Arbor Healthcare System, Ann Arbor, Michigan | 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 Jackson VA Outpatient Clinic.
Closure Date:
2 We recommended that employees at the Jackson VA Outpatient Clinic receive the required training on hazardous materials.
Closure Date:
3 We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Jackson VA Outpatient Clinic.
Closure Date:
4 We recommended that fire drills are performed every 12 months at the Jackson VA Outpatient Clinic.
Closure Date:
5 We recommended that the information technology server closet at the Jackson VA Outpatient Clinic is maintained according to information technology safety and security standards.
Closure Date:
6 We recommended that the staff at the Jackson VA Outpatient Clinic receive regular information/updates on their responsibilities in emergency response operations.
Closure Date:
7 We recommended that the staff at the Jackson VA Outpatient Clinic participate in scheduled emergency management training and exercises.
Closure Date:
8 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
9 We recommended that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
10 We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
11 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:
12 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
13 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 15-00113-161 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of West Palm Beach VA Medical Center, West Palm Beach, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Delray Beach, FL, CBOC and that compliance is monitored.
Closure Date:
2 We recommended that patient-identifiable information on laboratory specimens is protected during transport from the Delray Beach, FL, CBOC to the parent facility.
Closure Date:
3 We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Delray Beach, FL, CBOC.
Closure Date:
4 We recommended that 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:
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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15160