Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00919-228 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at New Mexico VA Health Care System, Albuquerque, New Mexico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that patients’ personally identifiable information is protected and secured at the Truth or Consequences CBOC.
2 We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
3 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.
4 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
5 We recommended that staff provide medication counseling/education as required.
6 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
7 We recommended that clinical executive/primary care leaders ensure that CBOC/Primary Care Clinic Designated Women’s He
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.
| ||||
| 14-02063-231 | Combined Assessment Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently initiated.
Closure Date:
2 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
3 We recommended that processes be strengthened to ensure 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:
4 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in outlier data, bar codes that were unable to scan, and blood transfusions.
Closure Date:
5 We recommended that processes be strengthened to ensure that nurse call system alarms are functional 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 stroke guidelines be posted in the emergency department, on the critical care units, and on the medical and surgical units.
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 staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Closure Date:
| ||||
| 14-00921-223 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Washington DC VA Medical Center, Washington, DC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that external signage is installed that clearly identifies the building as a VA CBOC at the Southern Prince George's County CBOC.
Closure Date:
2 We recommended that managers ensure all interior signs clearly identify the route to and location of the Southern Prince George's County CBOC.
Closure Date:
3 We recommended that the clinic entrance door access is Americans with Disabilities Act accessible at the Southern Prince George's County CBOC.
Closure Date:
4 We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Southern Prince George's County CBOC.
Closure Date:
5 We recommended that signage is installed at the Southern Prince George's County CBOC to clearly identify the location of all fire extinguishers.
Closure Date:
6 We recommended that signage is installed at the Southern Prince George's County CBOC to clearly identify emergency exits from any direction.
Closure Date:
7 We recommended that the information technology server closet at the Southern Prince George's County CBOC is secured according to information technology safety and security standards.
Closure Date:
8 We recommended that the CBOC/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:
| ||||
| 14-01294-224 | Combined Assessment Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Clinical Executive Council document its discussion of Peer Review Committee quarterly summary reports, including unusual findings or patterns.
Closure Date:
2 We recommended that a local observation bed policy that includes all required elements be implemented.
Closure Date:
3 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:
4 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
5 We recommended that the Surgical Staff Committee meet monthly, include the Chief of Staff as a member, and document its review of National Surgery Office reports.
Closure Date:
6 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed and data analyzed at least quarterly and that the review of electronic health record quality
Closure Date:
7 We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
Closure Date:
8 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:
9 We recommended that processes be strengthened to ensure that employees reprocess ophthalmology lenses and pachymetry probes in accordance with manufacturers¿ instructions and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 8 hours of admission and that compliance be monitored.
Closure Date:
11 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.
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 stroke guidelines be posted on all acute inpatient units.
Closure Date:
14 We recommended that the facility collect and report to the 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:
15 We recommended that processes be strengthened to ensure that contrast reaction drills are conducted in the magnetic resonance imaging mobile unit at the Hot Springs division and that compliance be monitored.
Closure Date:
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.
Closure Date:
| ||||
| 14-01497-188 | Inspection of VA Regional Office St. Louis, Missouri | Review | ||
1 We recommended the St. Louis VA Regional Office Director develop and implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommended the St. Louis VA Regional Office Director develop and implement a plan to review for accuracy the 559 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
Closure Date:
3 We recommended the St. Louis VA Regional Office Director implement a plan to ensure compliance with local policy requiring staff assigned to a specialized team process traumatic brain injury and special monthly compensation claims.
Closure Date:
4 We recommended the St. Louis VA Regional Office Director clarify local policy by clearly defining which special monthly compensation claims require processing by a specialized team.
Closure Date:
5 We recommended the St. Louis VA Regional Office Director implement a plan to ensure staff comply with local policy requiring Decision Review Officers to conduct second-signature reviews of special monthly compensation claims.
Closure Date:
6 We recommended the St. Louis VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Closure Date:
| ||||
| 14-01290-222 | Combined Assessment Program Review of the South Texas Veterans Health Care System, San Antonio, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
Closure Date:
2 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that damaged doors and floors and rusted lockers in patient care areas are repaired and that ongoing maintenance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service.
Closure Date:
5 We recommended that processes be strengthened to ensure that physicians complete and document discharge progress notes or patient discharge instructions and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinicians complete and document the National Institutes of Health Stroke Scale for each stroke patient and that compliance be monitored.
Closure Date:
7 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:
8 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.
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 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 document resident progress towards restorative nursing goals 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 the restorative registered nurse or designee signs and provides feedback, if indicated, on restorative aide notes.
Closure Date:
14 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
Closure Date:
15 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:
16 We recommended that processes be strengthened to ensure that secondary patient safety screenings are reviewed by Level 2 magnetic resonance imaging personnel on the same day as the magnetic resonance imaging and that compliance be monitored.
Closure Date:
17 We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
Closure Date:
18 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:
19 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.
Closure Date:
| ||||
| 14-00916-218 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that external signage clearly identifies the building as a VA CBOC at the Fort Stockton CBOC.
Closure Date:
2 We recommended that managers maintain a clean and functioning environment of care at the Hobbs CBOC.
Closure Date:
3 We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
4 We recommended that managers ensure staff can access the electronic version of the chemical inventory at the Abilene and San Angelo CBOCs.
Closure Date:
5 We recommended that processes are improved to ensure the tracking of chemical inventories at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
6 We recommended that the effectiveness of the panic alarm system is evaluated at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
7 We recommended that a separate room is provided to store medical (infectious) waste at the Hobbs CBOC.
Closure Date:
8 We recommended that fire drills are performed every 12 months at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
Closure Date:
9 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Abilene and San Angelo CBOCs to the parent facility.
Closure Date:
10 We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Fort Stockton CBOC.
Closure Date:
11 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Fort Stockton CBOC.
Closure Date:
12 We recommended that the information technology server closets at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs are maintained according to information technology safety and security standards.
Closure Date:
13 We recommended that the parent facility document Emergency Management Preparedness-specific training completed by the West Texas VA Health Care System CBOC clinical providers.
Closure Date:
14 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
15 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:
16 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
17 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:
18 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.
Closure Date:
19 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:
20 We recommended that staff provide medication counseling/education as required.
Closure Date:
21 We recommended that staff document the evaluation of patient's level of understanding for the medication education.
Closure Date:
| ||||
| 14-00931-213 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at John D. Dingell VA Medical Center, Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to PACT.
Closure Date:
2 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:
3 We recommended that staff provide medication counseling/education as required.
Closure Date:
| ||||
| 14-01322-215 | Healthcare Inspection – Quality of Care and Staff Safety Concerns at the Huntsville Community Based Outpatient Clinic, Huntsville, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensures that documentation of treatment with opioid medications meets Veterans Health Administration requirements.
Closure Date:
2 We recommended that the Facility Director ensures that staff consistently document responses to abnormal test results.
Closure Date:
3 We recommended that the Facility Director ensures that patients are notified of test results within the defined timeframe and that notification is documented in accordance with Veterans Health Administration requirements.
Closure Date:
4 We recommended that the Facility Director ensures that staff adhere to the facility policy for the management of non-VA medical records.
Closure Date:
5 We recommended that the Facility Director ensures that Community Based Outpatient Clinic provider privileges are in accordance with Veterans Health Administration requirements.
Closure Date:
6 We recommended that the Facility Director ensures the mental health standard operating procedure is updated to incorporate all procedures available for management of a mental health emergency at the Community Based Outpatient Clinic.
Closure Date:
7 We recommended that the Facility Director ensures that Community Based Outpatient Clinic panic alarms are functional.
Closure Date:
8 We recommended that the Facility Director ensures that a pain management policy is implemented.
Closure Date:
9 We recommended that the Facility Director ensures that the quality of entries in the electronic health record is reviewed at least quarterly.
Closure Date:
| ||||
| 13-03899-216 | Administrative Investigation, Prohibited Personnel Practice and Preferential Treatment, National Cemetery Administration, VA Central Office | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff confer with OHR and OGC to determine the appropriate corrective action to take, if any, as it relates to the two applicants listed on the certificate of eligibles who were not afforded the same preference in this hiring effort.
Closure Date:
2 We recommend that the VA Chief of Staff confer with OGC to review any active contracts with Ms. Noonan to ensure there is no organizational conflict of interest, as well as determine the appropriateness of the sole-source one-to-one contracts, and take the appropriate corrective action, if any.
Closure Date:
| ||||
15303