Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00228-94 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Overton Brooks VA Medical Center, Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that all identified environment of care deficiencies at the Monroe CBOC are reported to and tracked by the parent facility Executive Safety Committee until resolution.
2 We recommended that the parent facility include staff at the Monroe CBOC in required education, training, planning, and participation in annual disaster exercises.
3 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
4 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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.
6 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
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| 14-00233-96 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Caribbean Health Care System, San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that the hazardous materials inventory for the Arecibo CBOC is reviewed at least twice yearly.
Closure Date:
2 We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Arecibo CBOC to the parent facility.
Closure Date:
3 We recommended that managers ensure that women veterans can access gender-specific restrooms without entering public areas at the Arecibo CBOC.
Closure Date:
4 We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
Closure Date:
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| 13-03549-92 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
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| 13-03653-91 | Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the PRC.
Closure Date:
2 We recommended that the PRC submit quarterly summary reports to the MEC and that the MEC document its discussion of the reports.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and collects code data.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly and document its review of required performance data elements and National Surgical Office reports.
Closure Date:
5 We recommended that the quality control policy for scanning include how to annotate a scanned image to identify that it has been scanned.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Anesthesia Service representative attends Blood Usage Committee meetings and that the blood/transfusion usage review process includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
Closure Date:
7 We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that all locked MH unit staff, MSIT members, and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, 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:
9 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response times.
Closure Date:
10 We recommended that the locked MH unit¿s seclusion room door open towards the hallway and that patients in seclusion have privacy while using the bathroom.
Closure Date:
11 We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
Closure Date:
12 We recommended that all members of CLC-2's unit-based expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
13 We recommended that the newly established interprofessional pressure ulcer committee continue to meet and that the committee provide oversight of the facility's pressure ulcer prevention program.
Closure Date:
14 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:
15 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:
16 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
Closure Date:
17 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:
18 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education to patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that all employees who perform restorative nursing services receive training on and competency assessment for ROM and resident transfers.
Closure Date:
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| 13-03623-89 | Combined Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the ICU Committee reviews each code episode.
Closure Date:
2 We recommended that the MRC analyze all reports of EHR quality review results
Closure Date:
3 We recommended that processes be strengthened to ensure that a member from Surgery Service attends Ancillary Testing Committee meetings, that a clinical representative from Anesthesia Service is added as an Ancillary Testing Committee member, and that the blood/transfusions usage review process includes the results of peer reviews when transfusions did not meet criteria.
Closure Date:
4 We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
Closure Date:
5 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:
6 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff provide timely restorative nursing services to residents who are candidates for those services and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify interventions as needed, and document the modifications and that compliance be monitored.
Closure Date:
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| 13-03420-85 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Salt Lake City Health Care System, Salt Lake City, Utah | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the main entrance door access is ADA accessible at the Roosevelt CBOC.
Closure Date:
2 We recommended that gowned women veterans have access to gender-specific restrooms without entering public areas at the Roosevelt CBOC.
Closure Date:
3 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
4 We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
Closure Date:
5 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
Closure Date:
7 We recommended that CBOC/PCC staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
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| 14-00224-83 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Orlando VA Medical Center, Orlando, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic alarms are tested as required and testing is documented at the Kissimmee and Orange City CBOCs.
Closure Date:
2 We recommended that panic alarm testing results are reported to the EOC Committee, and repairs or corrections of alarm failures are tracked to completion by the EOC Committee.
Closure Date:
3 We recommended that fire drills are performed every 12 months at the Kissimmee CBOC.
Closure Date:
4 We recommended that all deficiencies identified on EOC rounds at the Kissimmee and Orange City CBOCs are reported to the EOC Committee, and actions taken are tracked to completion.
Closure Date:
5 We recommended that CBOC/PCC RN Care Managers complete MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
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| 13-03424-74 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs.
Closure Date:
2 We recommended that panic alarm testing is documented at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs.
Closure Date:
3 We recommended that fire drills are performed every 12 months at the Fort Leonard Wood and Lake of the Ozarks CBOCs.
Closure Date:
4 We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Lake of the Ozarks and Mexico CBOCs.
Closure Date:
5 We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Mexico CBOC.
Closure Date:
6 We recommended that the parent facility include staff at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs in required education, training, planning, and participation in annual disaster exercises.
Closure Date:
7 We recommended that the parent facility document EMP-specific training completed for the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs clinical providers.
Closure Date:
8 We recommended that the parent facility's EMC evaluate the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff
Closure Date:
9 We recommended that staff consistently complete follow-up assessments for patients with a positive alcohol screen.
Closure Date:
10 We recommended that staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
11 We recommended that RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
Closure Date:
12 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:
13 We recommended that clinical executive/primary care leaders ensure that CBOC/PCC DWHPs maintain proficiency as required for the provision of women's health care.
Closure Date:
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| 13-04241-78 | Combined Assessment Program Review of the Boise VA Medical Center, Boise, Idaho | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
2 We recommended that the Surgical Invasive Procedure Committee includes the COS as a member, monitors surgery performance improvement activities, and documents its review of surgical deaths.
Closure Date:
3 We recommended that processes be strengthened to ensure that the review of EHR quality includes most services.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that discharge instructions are consistent with patients¿ identified post-discharge needs and include all elements required by VHA policy and that compliance be monitored.
Closure Date:
6 We recommended that the facility have a Veterans Health Education Coordinator and an active Veterans Health Education Committee.
Closure Date:
7 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
8 We recommended that all members of the facility expert panel receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
9 We recommended that processes be strengthened to ensure that SCC minutes include analysis of pressure ulcer data and that the SCC routinely reports program data to facility executive leadership.
Closure Date:
10 We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location and stage 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 the facility establish ongoing staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
13 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 or document reasons for discontinuing or not providing restorative nursing services and that compliance be monitored.
Closure Date:
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| 13-03655-84 | Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and completed.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on patients in acute beds and that they are completed on at least 75 percent of acute care patients.
Closure Date:
4 We recommended that processes be strengthened to ensure that members from Surgery and Anesthesia Services attend Blood Transfusion Committee meetings.
Closure Date:
5 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that expired medications and supplies are removed from patient care areas and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that aftercare needs are identified and included in discharge planning and discharge instructions.
Closure Date:
11 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services or supplies within the ordered/expected timeframe.
Closure Date:
12 We recommended that processes be strengthened to ensure that patients' and/or caregivers' knowledge and learning abilities are assessed during the inpatient stay.
Closure Date:
13 We recommended that nursing managers monitor the recently implemented staffing methodology.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon discharge and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date PU acquired for all patients with PUs and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
17 We recommended that processes be strengthened to ensure that staff consistently notify the wound care team when an admitted patient has a skin risk of 14 or below.
Closure Date:
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15303