Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00687-155 | Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group meet monthly.
Closure Date:
2 We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
Closure Date:
5 We recommended that the facility implement their plan to track OPPEs and present them to the Professional Standards Board within the timeframe required by local policy and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all MSIT members and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response time.
Closure Date:
8 We recommended that the locked MH units' seclusion room floors have a cushioned surface.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology implemented in October 2013.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Closure Date:
13 We recommended that processes be strengthened to ensure that inspection documentation includes the time of the inspection and the time when corrective actions occurred.
Closure Date:
14 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are consistently conducted and documented in Infection Control Committee minutes.
Closure Date:
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| 12-00177-138 | Audit of the Quick Start Program | Audit | ||
1 We recommend the Under Secretary for Benefits establish Veterans Service Network Operations Report capabilities to track claims from the date the Veterans Benefits Administration receives and establishes active servicemembers’ claims to the date of Servicemembers’ discharge from military service.
2 We recommend the Under Secretary for Benefits track and report claims-processing time prior to Servicemembers’ discharge in timeliness performance results for the Quick Start Program or its successor.
3 We recommend the Under Secretary for Benefits conduct recurring evaluations that identify needed staffing adjustments to ensure sufficient staff are allocated to accomplish the timeliness targets of the Quick Start Program or its successor.
4 We recommend the Under Secretary for Benefits require Consolidated Processing Site and intake site claims assistants staff obtain periodic training on identifying and processing claims submitted through the Quick Start Program or its successor.
5 We recommend the Under Secretary for Benefits modify Systematic Technical Accuracy Reviews to include a systematic review of claims processed through the Quick Start Program or its successor.
6 We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to analyze trends of systemic issues identified during Quality Review Team and Systematic Technical Accuracy Review evaluations of claims processed through the Quick Start Program or its successor.
7 We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to provide staff recurring training on systemic issues identified during trend analyses of Quality Review Team and Systematic Technical Accuracy Review results.
8 We recommend the Under Secretary for Benefits revise policies and procedures to clarify that evidence must establish a nexus linking veterans’ claimed conditions to military service regardless of diagnosis proximity to discharge.
9 We recommend the Under Secretary for Benefits require Consolidated Processing Site managers to ensure staff adhere to Veterans Benefits Administration policies related to service connection while processing claims received through the Quick Start Program or its successor.
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| 14-00685-156 | Combined Assessment Program Review of the VA Montana Health Care System, Fort Harrison, Montana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the MEC document its discussion of unusual findings or patterns from PRC quarterly summary reports.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
3 We recommended that the facility have a Surgical Work Group that meets monthly, includes the COS as a member, and documents its review of National Surgical Office reports.
Closure Date:
4 We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
Closure Date:
5 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians provide discharge instructions on all aftercare needs to patients and/or caregivers and document this in the EHR and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
Closure Date:
9 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
Closure Date:
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| 14-00657-144 | Interim Report - VBA's Efforts to Effectively Obtain Service Treatment Records and Official Military Personnel Files | Audit | ||
1 We recommend the Under Secretary for Benefits identify and implement options to help alleviate the file storage issues at the regional office in St. Petersburg, FL.
Closure Date:
2 We recommend the Under Secretary for Benefits ensure mailroom personnel date stamp service treatment record files and copies of official military personnel files on the day they are received at the regional office in St. Petersburg, FL.
Closure Date:
3 We recommend the Under Secretary for Benefits identify and implement options to improve timeliness of evidence mail processing at the regional office in St. Petersburg, FL.
Closure Date:
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| 13-03213-152 | Audit of VHA's Mobile Medical Units | Audit | ||
1 We recommended the Under Secretary for Health withhold funding for new mobile medical units until a comprehensive assessment is conducted to assess factors, such as the current composition of the mobile medical unit fleet, services provided, operational days and costs, and the effect on rural veterans’ access to health care.
Closure Date:
2 We recommended the Under Secretary for Health assign responsibility for developing mobile medical unit policies, objectives, and strategy, and for providing program oversight.
Closure Date:
3 We recommended the Under Secretary for Health assign responsibility for maintaining operational data on mobile medical units to ensure mobile medical unit resources can be used as part of VHA’s emergency preparedness plan.
Closure Date:
4 We recommended the Under Secretary for Health publish necessary policy and guidance to provide for effective and efficient mobile medical unit operations.
Closure Date:
5 We recommended the Under Secretary for Health implement a mechanism to ensure that mobile medical unit-specific operations and financial data, such as patient workload, services provided, and costs, are collected in the Veterans Health Administration’s Decision Support System.
Closure Date:
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| 14-00895-163 | Healthcare Inspection - VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid Therapy | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health ensure that the practice of prescribing acetaminophen is in compliance with acceptable standards.
Closure Date:
2 We recommended that the Under Secretary for Health ensure that VA's practice of routine and random urine drug tests prior to initiating and during take-home opioid therapy to confirm the appropriate use of opioids is in alignment with acceptable standards.
Closure Date:
3 We recommended that the Under Secretary for Health ensure that follow-up evaluations of patients on take-home opioids are performed timely.
Closure Date:
4 We recommended that the Under Secretary for Health ensure that opioid patients with active (not in remission) substance use receive treatment for substance use concurrently with urine drug tests.
Closure Date:
5 We recommended that the Under Secretary for Health ensure that VA's practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with acceptable standards.
Closure Date:
6 We recommended that the Under Secretary for Health ensure that medication reconciliation is performed to prevent adverse drug interactions.
Closure Date:
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| 14-00688-162 | Combined Assessment Program Review of the Canandaigua VA Medical Center, Canandaigua, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC Work Group minutes reflect that actions are taken in response to identified deficiencies.
Closure Date:
2 We recommended that the facility establish a policy for the safe use of fluoroscopic equipment and that compliance with the newly established policy be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that all designated x-ray/fluoroscopy employees receive annual fluoroscopy safety training.
Closure Date:
4 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
5 We recommended that processes be strengthened to ensure that restorative nursing staff consistently document weekly and monthly notes according to local policy and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that providers are notified of critical laboratory and abnormal radiology test results/values within the expected timeframe and that notification is documented in the EHRs.
Closure Date:
7 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 EHRs.
Closure Date:
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| 14-00236-153 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months at the Johnstown CBOC.
Closure Date:
2 We recommended that medications are secured and only accessible by those individuals who either dispense or administer medications at the State College CBOC and that compliance is monitored.
Closure Date:
3 We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Johnstown CBOC.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing 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 consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
7 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
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| 13-00054-148 | Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2013 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that completed improvement actions related to protected peer review are reported to the Peer Review Committee.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facility observation bed processes are guided by comprehensive policies and that usage is monitored.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that reviews of inpatients’ continuing stays are consistently completed.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ scanning processes are guided by comprehensive policies, that medical information is properly scanned into patients’ electronic health records, and that compliance is monitored.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for thorough review of individual resuscitation episodes.
Closure Date:
6 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
Closure Date:
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| 14-01288-145 | Combined Assessment Program Summary Report - Construction Safety at Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that inspections are completed at the designated frequency and by required members, that all required elements are documented, and that construction sites comply with applicable VA and Occupational Safety and Health Administration requirements.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that contractor tuberculosis risk assessments are conducted.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that facilities establish Construction Safety Committees; develop and implement written policies addressing committee responsibilities; assure required committee membership and participation; and ensure meeting minutes include consistent documentation of inspection results, follow-up actions to resolve unsafe conditions, and tracking of actions to completion.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that Infection Control Committee meeting minutes include consistent documentation of construction-related infection control surveillance activities and any necessary follow-up actions to identified trends or problems.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that designated facility staff receive required initial and biennial construction safety training.
Closure Date:
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15303