Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02198-284 | Community Based Outpatient Clinic Summary Report — Evaluation of CBOC Cervical Cancer Screening and Results Reporting | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying ordering providers of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Closure Date:
2 We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying women veterans of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Closure Date:
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| 14-02357-270 | Inspection of VA Regional Office Chicago, Illinois | Review | ||
1 We recommended the Chicago VA Regional Office Director conduct a review of the 581 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommended the Chicago VA Regional Office Director provide oversight to ensure staff follow Veterans Benefits Administration guidance for establishing suspense diaries and processing reminder notifications.
Closure Date:
3 We recommended the Chicago VA Regional Office Director ensure staff receive refresher training on the proper processing of special monthly compensation and ancillary benefits and implement a plan to ensure the effectiveness of the training.
Closure Date:
4 We recommended the Chicago VA Regional Office Director develop and implement a plan to ensure completion of all Systematic Analyses of Operations.
Closure Date:
5 We recommended the Chicago VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff take timely action on claims requiring rating decisions for reduction of benefits.
Closure Date:
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| 14-03736-273 | Review of Alleged Data Manipulation at the Los Angeles VA Regional Office | Audit | ||
1 We recommended the Los Angeles VA Regional Office Director take action to review and correct all entries the employee made in the electronic system on the 14 claims we identified.
Closure Date:
2 We recommended the Los Angeles VA Regional Office Director ensure monitoring of all employees’ work for the future to ensure that all work is performed in accordance with VBA policy.
Closure Date:
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| 14-00926-281 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Alexandria VA Health Care System, Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
2 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.
3 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
4 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.
5 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
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| 14-02072-283 | Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility implement a quality control policy for scanning that includes all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that infection prevention educational materials are available for eye clinic patients, visitors, and family members.
Closure Date:
3 We recommended that processes be strengthened to ensure that dirty items in the eye clinic are not stored in patient care areas and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that employees reprocess ophthalmology pachymetry probes in accordance with manufacturer's instructions and that compliance be monitored.
Closure Date:
5 We recommended that facility policy be amended to include that Controlled Substances Coordinators must be free from conflicts of interest, that controlled substances inspectors must be appointed in writing, and that annual updates for controlled substances inspectors include problematic issues identified through external survey findings and other quality control measures.
Closure Date:
6 We recommended that the facility develop instructions for inspections of automated dispensing machines.
Closure Date:
7 We recommended that processes be strengthened to ensure that the medical information from non-VA hospitalizations is consistently scanned into the electronic health records and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that licensed independent practitioners are notified of critical laboratory test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that safety plans contain documentation of assessment of available lethal means and ways to keep the environment safe and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that patients and/or their families receive a copy of the safety plan and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that written agreements acknowledging resident responsibility for medication security are in place in the domiciliary and the Domiciliary Care for Homeless
Closure Date:
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| 14-00938-272 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Minneapolis VA Health Care System, Minneapolis, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/Primary Care 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:
2 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 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:
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 was 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:
7 We recommended that clinical executive/primary care leaders ensure that CBOC/Primary Care Clinic Designated Women's Health Providers maintain proficiency as required for the provision of women's health care.
Closure Date:
8 We recommended that the chief of staff consistently ensure that all Designated Women's Health Providers are designated with the women's health indicator in the Primary Care Management Module.
Closure Date:
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| 14-02069-268 | Combined Assessment Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings.
Closure Date:
2 We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that auditory privacy is maintained in all intake areas, that managers stress to staff that sensitive patient information should not be discussed in public areas, and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that all designated eye clinic employees receive eye laser safety training with the frequency required by local policy and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that clinicians document patient/caregiver understanding of discharge instructions and that compliance be monitored.
Closure Date:
6 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:
7 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents¿ care plans and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that staff modify restorative nursing interventions as needed and document the modifications and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff document the reasons for not providing restorative nursing services when those services are care planned and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that hand-off communication occurs between Physical Medicine and Rehabilitation Service and the community living center when residents are discharged from therapy to ensure that restorative nursing services occur.
Closure Date:
14 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on range of motion and resident transfers.
Closure Date:
15 We recommended that processes be strengthened to ensure that staff document residents' restorative progress weekly and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
Closure Date:
17 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:
18 We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
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| 14-00271-265 | Healthcare Inspection – Emergency Department Staffing and Patient Safety Issues, VA San Diego Healthcare System, San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director implement a policy that includes a plan for additional registered nurses, providers, and support staff to augment the Emergency Department in times of acute overload or disaster.
Closure Date:
2 We recommended that the System Director review the orientation processes for registered nurses floating to the Emergency Department to ensure that the orientation provided is adequate and documented consistently.
Closure Date:
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| 14-02066-266 | Combined Assessment Program Review of the Providence VA Medical Center, Providence, Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that completed actions from peer reviews are reported to the Peer Review Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Special Care Committee collects data that measures performance in responding to codes.
Closure Date:
3 We recommended that the Surgical Service Staff Committee meet monthly.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee meets at least quarterly and that the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
5 We recommended that processes be strengthened to ensure that when data analysis indicates problems or opportunities for improvement, actions are consistently identified, implemented, and followed to resolution in surgical performance improvement activities, electronic health record quality reviews, and blood/transfusion reviews.
Closure Date:
6 We recommended that processes be strengthened to ensure that all patient care areas and public restrooms are clean and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that procedures for terminal cleaning of patient rooms are followed and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that in patient care areas, damaged furniture is repaired or removed from service and damaged surfaces are repaired and that compliance be monitored.
Closure Date:
9 We recommended that the pharmacy clean room for compounding sterile products be brought into compliance with United States Pharmacopeia 797> cleanliness, sterility, and monitoring standards.
Closure Date:
10 We recommended that processes be strengthened to ensure that all required members of the Environment of Care Committee consistently attend committee meetings, that the program be strengthened to ensure effective surveillance activities, and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that VA Police update the facility’s Security Management Plan annually and submit quarterly security reports to the Environment of Care Committee.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
14 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that clinician assessment of patients presenting with stroke symptoms includes facility required PTT and PT/INR tests and that compliance be monitored.
Closure Date:
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| 14-02068-264 | Combined Assessment Program Review of the Grand Junction VA Medical Center, Grand Junction, Colorado | 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.
2 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.
3 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings.
5 We recommended that nurse call systems be installed in the emergency department.
6 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and expired medications are promptly removed from patient care areas and that compliance be monitored.
7 We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
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.
9 We recommended that stroke guidelines be posted in the emergency department, on the critical care unit, and on all inpatient units.
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
11 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
12 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.
13 We recommended that processes be strengthened to ensure that the Restorative Care Coordinator documents patient restorative program goals and progress weekly in accordance with facility policy and that compliance be monitored.
14 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and documented in patients’ electronic health records and that compliance be monitored.
15 We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and placed in patients’ electronic health records, that any contraindications are identified and resolution documented prior to the scan, that Level 2 personnel conducting the secondary screenings sign the forms prior to the scan, and that compliance be monitored.
16 We recommended that the facility implement processes to monitor compliance with colorectal cancer timeliness and patient notification requirements.
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15303