Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02064-252 | Combined Assessment Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
2 We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Medical Executive Committee.
3 We recommended that the Surgical Work Group meet monthly and consistently document its review of National Surgical Office reports.
4 We recommended that processes be strengthened to ensure that data from electronic health record quality reviews are analyzed at least quarterly.
5 We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
6 We recommended that processes be strengthened to ensure that the Tissue and Transfusion Committee member from Anesthesia Service consistently attends meetings.
7 We recommended that processes be strengthened to ensure that damaged optical examination chairs in the eye clinics are repaired or removed from service.
8 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.
9 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.
10 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
11 We recommended that processes be strengthened to ensure that staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
12 We recommended that the facility collect and report to VHA 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.
13 We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
14 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
15 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.
16 We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
17 We recommended that appropriate signage and barriers be in place at the Leavenworth division to restrict access to magnetic resonance imaging Zone III.
18 We recommended that the Magnetic Resonance Imaging Safety Committee and the Patient Safety Manager evaluate the identified potential safety and security risks and take appropriate actions.
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| 14-04003-298 | Review of Alleged Data Manipulation at the VA Regioinal Office Houston, TX | Audit | ||
1 We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear, change, or cancel controls for claims.
Closure Date:
2 We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
Closure Date:
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| 13-04005-296 | Healthcare Inspection – Out of Operating Room Airway Management Concerns, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the facility’s out of operating room airway management policy is updated to include all Veterans Health Administration requirements.
Closure Date:
2 We recommended that the Facility Director ensure that processes be strengthened to complete out of operating room airway management training and competency requirements as outlined by Veterans Health Administration and local policies.
Closure Date:
3 We recommended that the Facility Director ensure that processes be strengthened to provide out of operating room airway management coverage as required.
Closure Date:
4 We recommended that the Facility Director ensure that highly portable video laryngoscope equipment is immediately available
Closure Date:
5 We recommended that the Facility Director ensure that analysis of the five patient care events identified in this report is completed as required.
Closure Date:
6 We recommended that the Facility Director ensure that the scopes of practice are updated for non-licensed independent practitioners who perform out of operating room airway management.
Closure Date:
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| 14-00927-293 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Long Beach Healthcare System, Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic alarms are tested, and testing is documented at the Santa Ana CBOC.
Closure Date:
2 We recommended that the parent facility's Emergency Management Committee evaluate emergency preparedness activities, participation in annual disaster exercise, and staff training/education related to emergency preparedness requirements at the Santa Ana CBOC.
Closure Date:
3 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that CBOC/Primary Care 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 staff document that medication reconciliation is completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
Closure Date:
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| 14-02889-310 | Inspection of VA Regional Office White River Junction, Vermont | Review | ||
1 The VA Regional Office should implement a plan to ensure staff timely process rating reductions and medical reexamination requests for temporary 100 percent disability evaluations.
Closure Date:
2 The VA Regional Office should conduct a review of the 33 temporary 100 percent disability evaluations remaining from the inspection universe and take appropriate action.
Closure Date:
3 The VA Regional Office should provide staff with refresher training on the proper processing of special monthly compensation claims and implement a plan to assess the effectiveness of that training.
Closure Date:
4 The VA Regional Office should implement a plan to strengthen the additional level of review for special monthly compensation claims.
Closure Date:
5 The VA Regional Office should implement a plan, and assess the effectiveness of the plan, to ensure completion, and adequate and continuous oversight of Systematic Analyses of Operations requirements.
Closure Date:
6 The VA Regional Office should implement a plan for training, and assess the effectiveness of the training, to ensure completion of Systematic Analyses of Operations requirements.
Closure Date:
7 The VA Regional office should implement a plan to ensure oversight and processing of benefit reduction cases.
Closure Date:
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| 14-00928-291 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bath VA Medical Center, Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers complete required training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 14-02075-292 | Combined Assessment Program Review of the Bath VA Medical Center, Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
Closure Date:
2 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:
3 We recommended that processes be strengthened to ensure that the Morbidity and Mortality Committee review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
4 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:
5 We recommended that the facility consistently 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:
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| 13-03065-304 | Administrative Investigation, Conduct Prejudicial to the Government and Interference of a VA Official for the Financial Benefit of a Contractor, Veterans Health Administration, Procurement & Logistics Office, Washington, DC | Administrative Investigation | ||
1 We recommend that the PDUSH confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against Ms. Taylor.
2 We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against Mr. Ryan.
3 We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the VHA Lead Contracting Specialist.
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| 14-00929-287 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the CBOC is Americans with Disabilities Act accessible at the Maury County CBOC.
Closure Date:
2 We recommended that managers ensure staff can access the electronic version of hazardous materials information at the Maury County CBOC.
Closure Date:
3 We recommended that processes are improved to ensure the tracking of hazardous materials at the Maury County CBOC.
Closure Date:
4 We recommended that the effectiveness of the panic alarm system is evaluated at the Maury County CBOC.
Closure Date:
5 We recommended that signage is installed at the Maury County CBOC to clearly identify the location of fire all extinguishers.
Closure Date:
6 We recommended that medications are secured and accessible only by individuals who either dispense or administer medications at the Maury County CBOC, and that compliance is monitored.
Closure Date:
7 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Maury County CBOC to the parent facility.
Closure Date:
8 We recommended that that that the information technology server closet at the Maury County CBOC is maintained according to information technology safety and security standards.
Closure Date:
9 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:
10 We recommended that CBOC and Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
11 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
12 We recommended that staff consistently provide patients with medication counseling and written medication information that includes the fluoroquinolone.
Closure Date:
13 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Closure Date:
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| 14-01502-259 | Inspection of VA Regional Office Seattle, Washington | Review | ||
1 We recommend the Seattle VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
2 We recommend the Seattle VA Regional Office Director implement a plan to review for accuracy the 576 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
3 We recommend the Seattle VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on processing claims related to special monthly compensation and ancillary benefits and implement a plan to monitor the effectiveness of that training.
4 We recommend the Seattle VA Regional Office Director amend its secondary-review policy by reducing the special monthly compensation threshold for requiring second-signature reviews as a means of ensuring accuracy in processing these complex claims.
5 We recommend the Seattle Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
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15303