Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00589-137 | Audit of the Non-Recurring Maintenance Program | Audit | ||
1 We recommend the Under Secretary for Health establish a process to track VA medical facilities' expenditure of NRM funds toward addressing the maintenance backlog.
Closure Date:
2 We recommend the Under Secretary for Health establish procedures to ensure VA medical facilities projects address the Facility Condition Assessment deficiencies as approved under the Strategic Capital Investment Plan.
Closure Date:
3 We recommend the Under Secretary for Health establish procedures to identify non-recurring maintenance projects that are not meeting milestones to ensure that timely corrective actions are taken.
Closure Date:
4 We recommend the Under Secretary for Health develop clearly defined criteria for assigning risk levels to building infrastructure systems reviewed by Facility Condition Assessment contractors.
Closure Date:
5 We recommend the Executive in Charge for the Office of Management and Chief Financial Officer increase financial accountability by implementing standardized accounting procedures for tracking NRM projects' financial performance.
Closure Date:
6 We recommend the Principal Executive Director, Office of Acquisition, Logistics and Construction instruct contract engineers to assign risk levels to identified maintenance deficiencies based on VHA criteria.
Closure Date:
7 We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction review Facility Condition Assessment estimating processes and procedures to ensure compliance with industry best practices.
Closure Date:
8 We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction review historical project costs to determine an effective adjustment factor to better estimate contract costs to complete the repair of identified maintenance deficiencies.
Closure Date:
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| 14-00689-142 | Combined Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are completed within the timeframe required by facility bylaws.
Closure Date:
2 We recommended that processes be strengthened to ensure that EOC Committee and Administrative Executive Committee minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
Closure Date:
3 We recommended that processes be strengthened to ensure that medication/supply carts are secured at all times and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that Nursing Service is represented at Radiation Safety Committee meetings.
Closure Date:
5 We recommended that managers initiate timely actions to address deficiencies identified during annual physical security surveys.
Closure Date:
6 We recommended that processes be strengthened to ensure that pharmacy inspections are consistently completed on the same day they were initiated and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections, daily public area inspections and bed checks, and weekly contraband inspections are completed and documented and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that medications in resident rooms on the MH RRTP units are secured and daily inspections for this are documented and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that written agreements acknowledging MH RRTP resident responsibility for medication security are documented and that compliance be monitored.
Closure Date:
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| 13-01819-133 | Healthcare Inspection - Improper Procurement and Billing Practices for Anesthesiology Services, George E. Wahlen VA Healthcare System, Salt Lake City, Utah | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health develop and implement a plan of action to ensure that VA purchase of medical services from affiliated academic institutions is in compliance with VA Directive 1663 and procurement laws and regulations.
Closure Date:
2 We recommended that the Under Secretary for Health ensure that VA prohibits the use of purchase orders to obtain contract provider services unless the purchase orders contain the required clauses identified in the report.
Closure Date:
3 We recommended that the Veterans Integrated Service Network Director ensure that the procurement of specialized medical services is in accordance with VA Directive 1663.
Closure Date:
4 We recommended that the Veterans Integrated Service Network Director ensure that Interim Contract Authority is appropriately granted and used as outlined in VA Directive 1663.
Closure Date:
5 We recommended that the VA Salt Lake City Health Care System Director develop and implement as necessary an alternate source plan for the provision of anesthesiology services that complies with VA Directive 1663.
Closure Date:
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| 14-01104-134 | Healthcare Inspection – Alleged Excessive Wait for Emergency Care and Staff Disrespect, VA Southern Nevada Healthcare System, Las Vegas, Nevada | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that action plans are developed and implemented to facilitate meeting and maintaining the facility's target of not more than 10 percent of emergency department patients should experience a length of stay exceeding 6 hours.
Closure Date:
2 We recommended that the Facility Director ensure that nursing staff reassess emergency department patients according to facility policy.
Closure Date:
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| 14-00227-131 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Birmingham VA Medical Center, Birmingham, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
2 We recommended that staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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.
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 consistently provide written medication information that includes the fluoroquinolone.
6 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
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| 14-00684-132 | Combined Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana | 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 PRC.
Closure Date:
2 We recommended that the MEC discuss and document its approval of the use of another facility's physicians for teledermatology services.
Closure Date:
3 We recommended that the facility obtain teledermatology physicians' professional practice evaluation information from the providing facility.
Closure Date:
4 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:
5 We recommended that processes be strengthened to ensure that the Acute Care Committee reviews each code episode and that code reviews consistently include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
6 We recommended that the recipient list for the automated e-mail notification for the patient incident reporting process is kept current.
Closure Date:
7 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
Closure Date:
8 We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
Closure Date:
9 We recommended that processes be strengthened to ensure that a member from Anesthesia Service attends Transfusion Utilization Committee meetings and that the blood/transfusions usage review process consistently includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
10 We recommended that the facility comply with VHA and local smoking policies and that compliance be monitored.
Closure Date:
11 We recommended that the VISN 11 Director establish a non-facility team to conduct a comprehensive EOC evaluation of the facility and ensure that deficiencies are corrected and that an action plan is developed to ensure the facility is properly cleaned and maintained.
Closure Date:
12 We recommended that the facility establish a policy for equipment inspection and testing and that compliance with the newly established policy be monitored.
Closure Date:
13 We recommended that signs be posted in waiting and procedure rooms within radiology asking female patients to notify staff if they may be pregnant.
Closure Date:
14 We recommended that processes be strengthened to ensure that expired medications are removed from radiology crash carts and clinical staff are trained on how to locate the crash cart expiration date and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on identifying and correcting environmental hazards, content and 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:
16 We recommended that the facility establish an interprofessional pressure ulcer committee.
Closure Date:
17 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
Closure Date:
18 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:
19 We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
20 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:
21 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
22 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:
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| 14-00240-129 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Southern Arizona VA Health Care System, Tucson, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Casa Grande CBOC.
Closure Date:
2 We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Casa Grande, Green Valley, and Safford CBOCs.
Closure Date:
3 We recommended that the information technology server closets at the Green Valley and Safford CBOCs are maintained according to information technology safety and security standards.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
5 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coach training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 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:
7 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Closure Date:
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| 14-00241-128 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at El Paso VA Health Care System, El Paso, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that external signage clearly identifies the building as a VA CBOC at the Eastside El Paso CBOC.
Closure Date:
2 We recommended that testing of the panic alarm system is documented at the Eastside El Paso 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 staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
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:
8 We recommended that staff document the evaluation of patient¿s level of understanding for the medication education.
Closure Date:
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| 14-00683-130 | Combined Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of completed FPPEs for newly hired licensed independent practitioners are consistently reported to the MEC.
Closure Date:
2 We recommended that processes be strengthened to ensure that Transfusion Committee members from Surgery and Anesthesia Services consistently attend meetings.
Closure Date:
3 We recommended that processes be strengthened to ensure that multi-dose medication vials are dated after initial use and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that all locked MH unit staff, ISIT 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:
6 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing includes VA Police response time and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that MH EOC Checklist inspections include participation by all required ISIT members and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that the ISIT assigns a risk level per identified deficiency at the time of acute MH unit inspections and that compliance be monitored.
Closure Date:
9 We recommended that nursing managers implement VHA's staffing methodology.
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 perform and document daily skin inspections and daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that all designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that staff do not provide medical treatments to residents during meals in the common dining area.
Closure Date:
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| 14-00239-127 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern Indiana Health Care System, Fort Wayne, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Community Based Outpatient Clinic/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that Community Based Outpatient Clinic/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:
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.
Closure Date:
4 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
5 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
6 We recommended that clinical executive/primary care leaders ensure that Community Based Outpatient Clinic/Primary Care Clinic Designated Women’s Health Providers maintain proficiency as required for the provision of women’s health care.
Closure Date:
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15303