Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
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| 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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| 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:
| ||||
| 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:
| ||||
| 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:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $593,000
Total: $593,000
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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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15303