Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 15-00032-226 | Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
Closure Date:
2 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
Closure Date:
3 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure personal protective equipment gowns, eye protection, and masks are available in various sizes in patient care areas and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure all designated critical care and community living center employees receive annual bloodborne pathogens training and monitor compliance.
Closure Date:
6 We recommended that the facility conduct initial patient safety screenings prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
7 We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
8 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:
9 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:
10 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:
11 We recommended that facility managers post stroke guidelines on the critical care and medical/surgical units.
Closure Date:
12 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility report to the Medical Executive Board 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:
14 We recommended that clinicians obtain cardiac markers, prothrombin time/international normalized ratio, and partial thromboplastin time while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
Closure Date:
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| 14-02916-336 | Review of VA's Patient-Centered Community Care (PC3) Contracts' Estimated Costs Savings | Audit | ||
1 We recommended the Interim Under Secretary for Health assign an accountable senior executive to prepare and document revised Patient-Centered Community Care price analyses and determine if VA will realize any cost savings during the future option years of the contracts.
Closure Date:
2 We recommended the Interim Under Secretary for Health develop an action plan to address low PC3 contract utilization rates.
Closure Date:
3 We recommended the Executive Director, Office of Acquisition, Logistics, and Construction ensure all required contract documents are maintained in the official Patient-Centered Community Care contract files in accordance with Federal Acquisition Regulation and hold the contracting officer accountable for ensuring complete and accurate information is maintained in the Electronic Contract Management System.
Closure Date:
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| 15-00114-212 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
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| 15-00123-211 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the information technology server closet at the Primary Care Team 2 Annex is maintained according to information technology safety and security standards.
Closure Date:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 15-00074-207 | Combined Assessment Program Review of the Veterans Health Care System of the Ozarks, Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
2 We recommended that the Intensive Care Unit Committee document the review of 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.
3 We recommended that the Chief of Staff attend Surgical Work Group meetings and that the Surgical Work Group document its review of National Surgical Office reports.
4 We recommended that the Facility Director approve and sign written requests for extensions for final peer reviews.
5 We recommended that Environment of Care Committee meeting minutes consistently include discussion regarding community based outpatient clinic rounds deficiencies.
6 We recommended that the Infection Control Committee meeting minutes consistently include implementation of actions to address all high-risk areas, follow-up on implemented actions, and analysis of surveillance activities and data.
7 We recommended that facility managers ensure patient care areas are in good repair and monitor compliance.
8 We recommended that the facility correctly tag critical medical equipment on the intensive care unit and inspect and maintain it as recommended by the manufacturer and that facility managers monitor compliance.
9 We recommended that the facility remove inoperable medical equipment from use.
10 We recommended that the facility annually review the look-alike and sound-alike medication list.
11 We recommended that the facility conduct a contrast reaction emergency drill in magnetic resonance imaging and that facility managers monitor compliance.
12 We recommended that 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.
13 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
14 We recommended that facility managers post stroke guidelines on all required units.
15 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
16 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
17 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.
18 We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
19 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.
20 We recommended that the facility develop and grant a scope of practice that includes emergency airway management for respiratory therapists who have established competency to perform the procedure.
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| 14-00378-208 | Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2014 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers complete improvement actions related to peer review and report the completion to the Peer Review Committee and that the Peer Review Committee submits quarterly reports to the Medical Executive Committee.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that the Medical Executive Committee documents approval when telemedicine services are received or provided.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers reassess observation criteria and/or utilization when the conversion rate from observation to admission was greater than the allowed percent.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinicians complete reviews of inpatients’ continuing stays.
Closure Date:
5 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirement for an interdisciplinary committee to review individual resuscitation episodes and for facilities to collect resuscitation data.
Closure Date:
6 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
Closure Date:
7 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for Surgical Work Groups to meet monthly, include the Chief of Staff as a member, monitor surgical performance improvement activities, and review National Surgery Office reports.
Closure Date:
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| 15-00030-202 | Combined Assessment Program Review of the Martinsburg VA Medical Center, Martinsburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Medical Executive Committee review privilege forms annually and document the review.
Closure Date:
2 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
Closure Date:
3 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
Closure Date:
4 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.
Closure Date:
5 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
6 We recommended that the facility secure sterile supply cabinets when not in use and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility promptly remove outdated commercial supplies from examination rooms and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure employees lock computers and secure sensitive patient information when they leave the area and monitor compliance.
Closure Date:
9 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
10 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:
11 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
12 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:
13 We recommended that facility managers ensure that intensive care unit, Emergency Department, and medical/surgical unit (4A) employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and completed and documented.
Closure Date:
14 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed and documented for employees on the intensive care unit.
Closure Date:
15 We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor competency.
Closure Date:
16 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and includes all required elements and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility correct the identified deficiencies in the domiciliary and that documentation reflect correction.
Closure Date:
18 We recommended that domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.
Closure Date:
19 We recommended that domiciliary program managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
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| 15-00121-201 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Veterans Health Care System of the Ozarks, Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a functional panic alarm system is installed at the Jay CBOC.
Closure Date:
2 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and 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:
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.
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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15303