Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-01708-123 | Healthcare Inspection – Staffing and Patient Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that senior leadership and nursing managers fully implement the VHA Nurse Staffing Methodology Plan as required.
Closure Date:
2 We recommended that the Facility Director ensure that senior leadership and nursing managers fully evaluate the medical intensive care and step down units' patient mix, staffing plan, patterns of floating, physical layout, and unit assignments for opportunities for improvement and take necessary action.
Closure Date:
3 We recommended that the Facility Director ensure that patient incident reporting processes be strengthened so that all patient incidents or safety concerns are reported promptly to the patient safety manager.
Closure Date:
4 We recommended that the Facility Director ensure that nursing staff perform and document fall risk assessments as required.
Closure Date:
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| 14-04389-106 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Erie VA Medical Center, Erie, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period.
2 We recommended that managers develop and communicate an egress plan for the safety of all patients.
3 We recommended that processes are strengthened to ensure that women veterans can access gender-specific restrooms without entering public areas.
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
6 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.
7 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.
8 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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| 14-04224-107 | Combined Assessment Program Review of the Erie VA Medical Center, Erie, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers monitor the recently revised reprivileging process to ensure practitioners have the appropriate skills and training for emergency airway management.
Closure Date:
2 We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
Closure Date:
3 We recommended that Medicine Service designate an Automated Data Processing Applications Coordinator.
Closure Date:
4 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
5 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:
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| 14-04378-97 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Hudson Valley Health Care System, Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff protect patient-identifiable information on laboratory specimens during transport from the Carmel CBOC 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 provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
Closure Date:
6 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:
7 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
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| 14-04223-100 | Combined Assessment Program Review of the VA North Texas Health Care System, Dallas, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Executive Quality, Safety, and Value Committee continue to meet and ensure that aggregated data is reviewed, that problems or opportunities for improvement are identified, that specific actions are documented, and that actions are fully implemented and monitored over time.
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.
3 We recommended that the Critical Care Committee review each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that the committee consistently collect code data.
4 We recommended that the Surgical Work Group meet monthly.
5 We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
6 We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document
does not meet image quality controls and a complete review of scanned documents to ensure readability and retrievability.
7 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.
8 We recommended that the facility conduct contrast reaction drills in the magnetic resonance imaging area and that facility managers monitor compliance.
9 We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
10 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.
11 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.
12 We recommended that the facility implement a stroke care designation appropriate to its inpatient acute care complexity.
13 We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
14 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
15 We recommended that facility managers post stroke guidelines in the Emergency Department and on the intensive care and acute inpatient care units.
16 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
17 We recommended that facility managers provide a stroke education program.
18 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.
19 We recommended that facility managers ensure that applicable Nursing Service employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and 12-lead electrocardiogram competency assessment and validation completed and documented.
20 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
21 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of scopes of practice and includes all required elements and that facility managers monitor compliance.
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| 14-04215-99 | Combined Assessment Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners' folders do not contain licensure verification information.
Closure Date:
2 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility appropriately protect computer monitors from public viewing on the medical and surgical units and that facility managers monitor compliance.
Closure Date:
4 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:
5 We recommended that the facility designate a committee to oversee consult management.
Closure Date:
6 We recommended that the Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
Closure Date:
7 We recommended that Radiology Service revise the computed tomography scan and magnetic resonance imaging on-call policy to require a 30-minute reporting time.
Closure Date:
8 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the surgical intensive care unit.
Closure Date:
9 We recommended that Domiciliary Care for Homeless Veterans and Post-Traumatic Stress Disorder Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Closure Date:
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| 14-04211-94 | Combined Assessment Program Review of the VA Hudson Valley Health Care System, Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure licensed independent practitioners trained to perform airway management are fully privileged.
Closure Date:
2 We recommended that the facility complete the conversion from the six-part credentialing and privileging folder to the two-part privileging folder.
Closure Date:
3 We recommended that the Emergency Response Committee document 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.
Closure Date:
4 We recommended that facility managers ensure public restrooms are free of insects and monitor compliance.
Closure Date:
5 We recommended that the facility clean and/or repair dirty/damaged wheelchairs in patient care areas or remove them from service.
Closure Date:
6 We recommended that facility managers ensure walk-off sticky mats are in place at construction site entrances to minimize dust, ensure site entrances are secured, and monitor compliance.
Closure Date:
7 We recommended that the facility not stock heparin in concentrations of more than 5,000 units per milliliter in patient care areas or document approval by the Chief of Pharmacy to stock in these concentrations.
Closure Date:
8 We recommended that the facility revise the plan for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
Closure Date:
10 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:
11 We recommended that the facility revise the stroke policy to address screening for difficulty swallowing and use of the National Institutes of Health Stroke Scale and tracking of its use and that the facility managers fully implement the revised policy.
Closure Date:
12 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:
13 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:
14 We recommended that the facility comply with Veterans Health Administration directive requirements for exempted facilities, or if the facility plans intubations during emergency responses, they comply with Veterans Health Administration requirements for non-exempted facilities.
Closure Date:
15 We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
Closure Date:
16 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility ensure a provider with completed emergency airway management privileges or a clinician with completed emergency airway management scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
18 We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
Closure Date:
19 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.
Closure Date:
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| 14-05132-90 | Combined Assessment Program Summary Report - Evaluation of Pressure Ulcer Prevention and Management at Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility policy addresses outpatient pressure ulcer prevention and treatment.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish pressure ulcer committees with appropriate professional representation.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities' pressure ulcer programs define requirements for employee training regarding pressure ulcer risk assessment, skin assessment and management, and documentation of skin assessment findings and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians revise pressure ulcer prevention plans when patients' risk levels change and that facility managers monitor compliance.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document patient/caregiver pressure ulcer education and that facility managers monitor compliance.
Closure Date:
6 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document skin inspections and Braden scales daily during hospitalization, including the day of discharge, and that facility managers monitor compliance.
Closure Date:
7 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish processes to monitor consistency in documentation of pressure ulcer stage, location, date acquired, and risk scale score and take appropriate actions to address inconsistencies.
Closure Date:
8 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians document wound care follow-up plans for patients discharged with unhealed pressure ulcers and that the facility provides needed supplies.
Closure Date:
9 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees secure medications stored in patients' rooms.
Closure Date:
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| 14-04219-98 | Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
2 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
3 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:
4 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:
5 We recommended that the facility create/designate a committee to oversee consult management.
Closure Date:
6 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:
7 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:
8 We recommended that scanned magnetic resonance imaging documents are accurate and complete and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
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 revise the emergency airway management policy to include demonstration of competency by both direct and video laryngoscopy.
Closure Date:
13 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:
14 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:
15 We recommended that facility managers ensure the Psychosocial Residential Rehabilitation Treatment Program environment is clean and monitor compliance.
Closure Date:
16 We recommended that the facility ensure that Psychosocial Residential Rehabilitation Treatment Program stained ceiling tiles are replaced, damaged baseboards and chipped wall tiles are repaired or replaced, and the emergency exit door is repaired.
Closure Date:
17 We recommended that clinicians document all required vaccination administration elements and that facility managers monitor compliance.
Closure Date:
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| 15-00430-103 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages | National Healthcare Review | ||
1 We recommended that the Interim Under Secretary for Health continue to develop and implement staffing models for critical need occupations.
Closure Date:
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15160