Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-04221-91 | Combined Assessment Program Review of the Memphis VA Medical Center, Memphis, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinicians consistently complete final peer reviews within required timeframes and obtain written requests for extensions approved by the Facility Director and that facility managers monitor compliance.
Closure Date:
2 We recommended that the Cardiopulmonary Resuscitation Committee fully review each code episode.
Closure Date:
3 We recommended that the Surgical Work Group meet monthly and include the Chief of Staff as a member.
Closure Date:
4 We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
5 We recommended that the quality control policy for scanning include all required elements.
Closure Date:
6 We recommended that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
Closure Date:
7 We recommended that Infection Control Committee meeting minutes reflect implementation of actions to address high-risk areas and provide sufficient follow-up actions to address identified problems.
Closure Date:
8 We recommended that facility managers ensure all designated critical care nurses receive hazardous material training and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure all negative pressure control systems in isolation rooms are functional and monitor compliance.
Closure Date:
10 We recommended that facility managers ensure all crash cart medications are current and daily crash cart inspections are consistently documented and include all required elements and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
Closure Date:
12 We recommended that facility managers ensure designated employees receive annual automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
13 We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
14 We recommended that requesters consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
Closure Date:
16 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:
17 We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
Closure Date:
18 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:
19 We recommended that facility managers post stroke guidelines in all areas where patients may present with stroke symptoms.
Closure Date:
20 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
21 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:
22 We recommended that facility managers ensure that nursing staff who perform 12-lead electrocardiograms have a current competency assessment and validation included in their competency checklists and have competency assessment and validation documentation completed.
Closure Date:
23 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists for employees on the post-anesthesia care unit.
Closure Date:
24 We recommended that the facility revise the emergency airway management policy to include all required Veterans Health Administration elements.
Closure Date:
25 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and a written exam and that facility managers monitor compliance.
Closure Date:
26 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:
27 We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
Closure Date:
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| 14-04218-92 | Combined Assessment Program Review of the St. Cloud VA Health Care System, St. Cloud, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 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:
| ||||
| 13-03324-85 | Follow-up Audit of the Information Technology Project Management Accountability System | Audit | ||
1 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish procedures to ensure the Office of Product Development completes all required Planning Reviews (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
2 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure personnel performing Compliance Reviews assess the accuracy and reasonableness of cost information reported on the Project Management Accountability System Dashboard (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
3 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure hiring actions are completed by acquiring the vacant Federal employee positions in the Project Management Accountability System Business Office (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
4 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, not exercise future options of the task order used to augment Project Management Accountability System Business Office staffing once hiring actions have been completed.
Closure Date:
5 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete modification of the Project Management Accountability System Dashboard so that it maintains a complete audit trail of baseline data by including planned, revised, and actual figures for project life-cycle and increment costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
6 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete development and implementation of a sound methodology to capture and report planned and actual total project and increment level costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
7 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure project managers capture and report reliable cost data and maintain adequate audit trails to support how the cost information reported on the Project Management Accountability System Dashboard was derived in the interim until actions to automate budget traceability and shift VA’s IT projects to increment-based contracts are completed (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
8 We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, clearly define the term “enhancement of an existing system or its infrastructure” and require Service Delivery and Engineering project teams to track and report costs associated with enhancements on the Project Management Accountability System Dashboard.
Closure Date:
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| 14-04451-88 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Illiana Health Care System, Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers maintain a clean and functioning environment of care at the Peoria CBOC.
Closure Date:
2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Peoria CBOC.
Closure Date:
3 We recommended that the information technology server closet at the Peoria CBOC is maintained according to information technology safety and security standards.
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:
| ||||
| 14-04382-86 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of St. Cloud VA Health Care System, St. Cloud, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months at the Brainerd CBOC.
Closure Date:
| ||||
| 14-04214-70 | Combined Assessment Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
Closure Date:
2 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
Closure Date:
3 We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
Closure Date:
4 We recommended that facility managers consult with the manufacturer regarding the issue of dirty-appearing sinks and take any recommended actions.
Closure Date:
5 We recommended that facility managers ensure all designated employees receive annual bloodborne pathogens training and monitor compliance.
Closure Date:
6 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:
7 We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
8 We recommended that requestors consistently include “inpatient” in the consult title 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 clinicians provide printed stroke education to patients upon discharge 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 revise the emergency airway management policy to include the availability of videolaryngoscopes for use by clinicians and a plan for managing a difficult airway.
Closure Date:
15 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:
16 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility complete at least two preventive ethics improvement cycles each fiscal year.
Closure Date:
18 We recommended that the facility consistently schedule follow-up appointments within the timeframes requested by providers.
Closure Date:
| ||||
| 14-02082-82 | Combined Assessment Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility establish a Surgical Work Group that meets monthly, includes all required members, and documents oversight of surgical performance improvement activities such as morbidity and mortality reviews.
Closure Date:
2 We recommended that that processes be strengthened to ensure that soiled utility rooms are secured at all times and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that public restrooms on the Department of Housing and Urban Development and VA Supportive Housing floor are clean and well maintained and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that auditory privacy is maintained in all interview areas on the Department of Housing and Urban Development and VA Supportive Housing floor and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that sterile supplies for same day surgery/the post-anesthesia care unit are stored in a secured room where appropriate temperature and humidity levels can be maintained and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
9 We recommended that stroke guidelines be posted on the critical care unit, in the emergency department, and on all inpatient units.
Closure Date:
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
11 We recommended that the facility collect and report to VHA 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 processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and documented in the electronic health record and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that medications in resident rooms are secured.
Closure Date:
14 We recommended that processes be strengthened to ensure that all domiciliary admission denials contain documentation regarding the reason for the denial and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
| ||||
| 14-04385-65 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Tomah VA Medical Center, Tomah, Wisconsin | 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 Wausau CBOC.
Closure Date:
2 We recommended that hand hygiene compliance is monitored at the Wausau CBOC and reported to the Infection Control Committee.
Closure Date:
3 We recommended that privacy is provided for veterans in the examination rooms at the Wausau CBOC.
Closure Date:
4 We recommended that the information technology server closet at the Wausau CBOC is maintained according to information technology safety and security standards.
Closure Date:
5 We recommended that the staff at the Wausau CBOC receive regular information and updates on their responsibilities in emergency response operations.
Closure Date:
6 We recommended that the staff at the Wausau CBOC participate in scheduled emergency management training and exercises.
Closure Date:
7 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
8 We recommended that RN Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
9 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:
10 We recommended that clinic staff ensures that written patient educational materials provided to patients prior to or at the time of consent for HIV testing include all required elements.
Closure Date:
| ||||
| 14-04383-78 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Memphis VA Medical Center, Memphis, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Savannah, TN, CBOC
receive the required training on hazardous materials.
2 We recommended that managers ensure that safety inspections
are performed on all the medical equipment at the Savannah, TN, CBOC in accordance with VA and Joint Commission standards.
3 We recommended that hand hygiene compliance be monitored
at the Savannah, TN, CBOC and reported to the Infection Control Committee.
4 We recommended that signage is installed at the Savannah, TN,
CBOC to clearly identify all exits.
5 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Savannah, TN, CBOC and that compliance is monitored.
6 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Savannah, TN, CBOC to the parent facility.
7 We recommended that examination tables and curtains provide adequate privacy for women veterans at the Savannah, TN, CBOC.
8 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Savannah, TN, CBOC.
9 We recommended that access to the information technology server closet at the Savannah, TN, CBOC is restricted and maintained according to information technology safety and security standards.
10 We recommended that access to the information technology server closet at the Savannah, TN, CBOC is documented consistently according to information technology safety and security standards.
11 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
12 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.
13 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.
14 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
| ||||
| 14-04210-63 | Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Medical Executive Committee and the Facility Director consistently review and approve revised privilege forms.
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 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 performance data.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly.
Closure Date:
5 We recommended that the facility share patient handling injury data.
Closure Date:
6 We recommended that facility managers ensure patient care area floors and public restrooms are clean and monitor compliance.
Closure Date:
7 We recommended that the facility repair damaged floors and wall surfaces in patient care areas.
Closure Date:
8 We recommended that the facility repair damaged wheelchairs and furnishings in patient care areas or remove them from service.
Closure Date:
9 We recommended that facility managers ensure all required members of the Environment of Care Committee consistently attend meetings and monitor compliance.
Closure Date:
10 We recommended that the facility use special medication labeling and/or institute unique storage practices for the complete list of look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure monthly medication storage area inspections are consistently completed and monitor compliance.
Closure Date:
12 We recommended that facility managers ensure that oral syringes are available for oral liquid medication administration and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
13 We recommended that the facility revise the local policy on inspection of medication storage areas to be consistent with Veterans Integrated Service Network policy.
Closure Date:
14 We recommended that major bed services have designated Automated Data Processing Applications Coordinators.
Closure Date:
15 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:
16 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:
17 We recommended that facility managers post stroke guidelines on the three inpatient units and in the two community living centers.
Closure Date:
18 We recommended that clinicians screen patients for difficulty swallowing, that screening be done prior to oral intake, and that facility managers monitor compliance.
Closure Date:
19 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
20 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:
21 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:
22 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and that facility managers monitor compliance.
Closure Date:
23 We recommended that the facility ensure 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:
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15160