Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00615-61 | Healthcare Inspection – Alleged Quality of Care and Courtesy Issues at the Alamosa Community Based Outpatient Clinic, Alamosa, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement the CBOC triage guidelines and train staff on the guidelines.
Closure Date:
2 We recommended that the Facility Director ensure that managers appropriately address CBOC staff who exhibit lapses in competency, when identified.
Closure Date:
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| 14-04380-79 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Mobile Outpatient Clinic CBOC receive the required training on hazardous materials.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that licensed Providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that the Facility Director identifies a Lead Human Immunodeficiency Virus Clinician to carry out required responsibilities.
Closure Date:
6 We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
Closure Date:
7 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
8 We recommended that clinic staff ensures that written patient educational materials are provided to patients prior to or at the time of consent for human immunodeficiency virus testing and include all required elements.
Closure Date:
9 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
10 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-02412-69 | Healthcare Inspection – Ophthalmology Service Concerns, VA Illiana Health Care System, Danville, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement all recommendations for interpersonal training for the staff and providers in the Ophthalmology and Optometry Services.
Closure Date:
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| 14-02073-57 | Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
Closure Date:
2 We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
Closure Date:
3 We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly and review relevant data elements.
Closure Date:
5 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Transfusion Review Committee members from Medicine, Surgery, and Anesthesia Services consistently attend meetings.
Closure Date:
7 We recommended that the facility¿s stroke policy/plan/guideline be revised to address screening for difficulty swallowing, that the policy/plan/guideline be fully implemented, and that compliance be monitored.
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 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:
10 We recommended that processes be strengthened to ensure that fire emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
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 that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure 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 compliance be monitored.
Closure Date:
14 We recommended that barriers are properly used to restrict access to magnetic resonance imaging Zone III and that compliance be monitored.
Closure Date:
15 We recommended that magnetic resonance imaging technologists have visual contact at all times with patients in the magnet room.
Closure Date:
16 We recommended that processes be strengthened to ensure that the two-way communication device is regularly tested and that compliance be monitored.
Closure Date:
17 We recommended that a Magnetic Resonance Imaging Safety Committee be appointed.
Closure Date:
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| 14-04368-56 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Samuel S. Stratton VA Medical Center, Albany, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the information technology server closet at the Polk Street VA Annex Clinic is maintained according to information technology safety and security standards.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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:
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 14-02887-64 | Healthcare Inspection – Quality of Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that patient safety incidents and concerns are reported promptly to the patient safety manager and that the need for further review and/or corrective actions is assessed initially by the patient safety manager.
Closure Date:
2 We recommended that the Facility Director ensure that cardiac resuscitation events in the operating room are appropriately documented and reviewed.
Closure Date:
3 We recommended that the Facility Director ensure that the Critical Incident Tracking Notification system recipient list includes the patient safety manager.
Closure Date:
4 We recommended that the Facility Director assess staffing in the Quality Management Service and take appropriate actions to meet the workload requirements.
Closure Date:
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| 14-00517-54 | Review of Alleged Mismanagement at VHA’s Massachusetts Veterans Epidemiology Research and Information Center | Audit | ||
1 We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, improve oversight controls to ensure Massachusetts Veterans Epidemiology Research and Information Center staff protects all veteran personal information in accordance with VA policy.
Closure Date:
2 We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, ensure that portable storage devices used by the Massachusetts Veterans Epidemiology Research and Information Center are encrypted.
Closure Date:
3 We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, ensure VA Boston Healthcare System Information Security Officers have full access to all VA Boston Healthcare System office space, including all Massachusetts Veterans Epidemiology Research and Information Center office space, in order to perform their oversight responsibilities.
Closure Date:
4 We recommended the Director of Veterans Integrated Service Network 1 develop an oversight and monitoring plan to ensure Massachusetts Veterans Epidemiology Research and Information Center staff comply with VA’s information security requirements.
Closure Date:
5 We recommended the Director of Veterans Integrated Service Network 1 implement a plan to maximize use of the off-site commercial space if continued need for the office space is justified.
Closure Date:
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| 13-00872-52 | Healthcare Inspection – Follow-Up Evaluation of Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn, VA Medical Center, Columbia, SC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that patient information, medical and surgical supplies, medications, grafts, and patches are stored properly throughout the facility and that compliance be monitored to ensure sustained improvement.
Closure Date:
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| 14-04705-62 | Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet | National Healthcare Review | ||
1 We recommended that the Interim Under Secretary for Health conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review.
Closure Date:
2 We recommended that the Interim Under Secretary for Health ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care.
Closure Date:
3 We recommended that after reviewing the circumstances of any inappropriate resolution of consults, the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
Closure Date:
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| 14-00351-53 | Healthcare Inspection – Alleged Inappropriate Opioid Prescribing Practices, Chillicothe VA Medical Center, Chillicothe, OH | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director identify patients receiving recurrent prescriptions for high potency and/or large quantity opioid medications and ensure appropriate periodic assessments.
Closure Date:
2 We recommended that the Facility Director ensure that prescribing physicians check the Ohio Automated Rx Reporting System for patients who are prescribed high potency and/or large quantity opioid medications.
Closure Date:
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15160