Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02073-106 | Healthcare Inspection – Administrative Irregularities, Leadership Lapses, and Quality of Care Concerns, VA Central Iowa Health Care System, Des Moines, Iowa | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated System Network Director ensure that the Chief of Staff appoints a director of the specific unit of the subject Service Line, who meets the qualification standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee.
2 We recommended that the Facility Director ensure that selection of physicians who will be participating in medical educational activities is conducted within the standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee and that compliance be monitored.
3 We recommended that the Facility Director ensure the implementation of a standardized process for the management of cardiology consults, consistent with VHA policy.
4 We recommended that the Facility Director ensure processes be strengthened so that Focused Professional Practice Evaluations for licensed independent practitioners are consistently conducted as required, and that compliance is monitored.
5 We recommended that the Facility Director ensure that the Chief of Staff maintain a comprehensive list of staff that is authorized to perform out of Operating Room airway management in compliance with facility policy.
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| 14-00308-105 | Combined Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 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.
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 the Blood Utilization Review Committee include a clinical representative from Surgery Service.
Closure Date:
4 We recommended that processes be strengthened to ensure that corrective actions are initiated and/or consistently followed to resolution when data analyses indicated problems or opportunities for improvement in the Performance Improvement, Medical Executive, and Executive Safety Committees.
Closure Date:
5 We recommended that processes be strengthened to ensure that patient care areas and restrooms are clean and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that holes in the walls are repaired and that ongoing maintenance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that all locked MH unit staff 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:
8 We recommended that the annual staffing plan reassessment process ensures that unit 6E's and unit 9E's unit-based expert panels include all required members.
Closure Date:
9 We recommended that processes be strengthened to ensure that Interprofessional Skin Integrity Committee minutes include data analysis.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score 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:
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| 13-01959-109 | Audit of VHA's Supportive Services for Veteran Families Program | Audit | ||
1 We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program implement a mechanism to inform grantees when updated area median income limits are published.
Closure Date:
2 We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program grantees follow up to obtain the required Certificate of Release or Discharge from Active Duty (DD 214) when interim documents are used to determine program eligibility.
Closure Date:
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| 14-00232-110 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Loma Linda Healthcare System, Loma Linda, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Rancho Cucamonga CBOC to the VA Loma Linda Healthcare System.
Closure Date:
2 We recommend that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
Closure Date:
4 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that CBOC/PCC RN Care Managers receive motivational interviewing training within 12 months of appointment to PACT.
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 provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
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| 13-03089-104 | Healthcare Inspection – Unexpected Patient Death in a Substance Abuse Residential Rehabilitation Treatment Program, Miami VA Healthcare System, Miami, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that the camera surveillance system is repaired and maintained and that surveillance is conducted as required on the SARRTP unit.
Closure Date:
2 We recommended that the System Director ensure that the SARRTP unit is appropriately staffed at all times, as required by VHA and local policy.
Closure Date:
3 We recommended that the System Director ensure that SARRTP staff implement a consistent and comprehensive approach to check patients returning to the unit for contraband and document results clearly.
Closure Date:
4 We recommended that the System Director ensure that SARRTP staff more aggressively monitor patients for illicit drug use, to include increasing the use of random UDS and adhering to local and VHA policy when patients leave the unit.
Closure Date:
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| 13-03620-102 | Combined Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that the Surgical Work Group meet monthly, include the Chief of Staff and VASQIP nurse as members, and document its review of National Surgical Office reports.
Closure Date:
3 We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on the 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:
4 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
5 We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scales daily, upon transfer, and at discharge and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stages and revise treatment plans when risk levels change and that compliance be monitored.
Closure Date:
7 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:
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| 13-03422-99 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
2 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
3 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
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 document the evaluation of patient’s level of understanding for the medication education.
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| 14-00306-95 | Combined Assessment Program Review of the VA Eastern Colorado Health Care System,Denver, Colorado | Comprehensive Healthcare Inspection Program | ||
1 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:
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 the Surgical Work Group meet monthly and include the Chief of Staff as a member.
Closure Date:
4 We recommended that the nurse staffing methodology be implemented.
Closure Date:
5 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
6 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
7 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
Closure Date:
8 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:
9 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:
10 We recommended that processes be strengthened to ensure that there are no unnecessary disruptions during resident meal periods.
Closure Date:
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| 14-00223-93 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Eastern Colorado Health Care System, Denver, Colorado | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
2 We recommended that all staff document that medication reconciliation was completed at each episode of care when the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
3 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Closure Date:
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| 13-03419-90 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Atlanta VA Medical Center, Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic alarms are tested and testing is documented.
Closure Date:
2 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
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15303