Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01488-86 | Administrative Investigation, Failure to Properly Supervise, Misuse of Official Time and Resources, and Prohibited Personnel Practice, VA Center for Innovation, VA Central Office | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff ensure that VBA conducts a review of all RVSRs to ensure that any not performing the functions of their position are either properly detailed or returned to their RVSR duties.
Closure Date:
2 We recommend that the VA Chief of Staff confer with the Office of Human Resources and Administration (OHRA) and the Office of General Counsel (OGC) to determine the appropriate administrative action, if any, to take against Mr. Bramlage.
Closure Date:
3 We recommend that the VA Chief of Staff confer with the OHRA and OGC to determine the appropriate administrative action, if any, to take against Ms. Yeary.
Closure Date:
4 We recommend that the VA Chief of Staff confer with the OHRA and OGC to determine the appropriate administrative action, if any, to take against Ms. Mullins.
Closure Date:
5 We recommend that the VA Chief of Staff ensure that Mr. Bramlage, Ms. Yeary, and Ms. Mullins receive appropriate refresher training in supervisory responsibilities for official travel, performance standards, and appraisals.
Closure Date:
6 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Moore.
Closure Date:
7 We recommend that the VA Chief of Staff ensure that Mr. Moore is issued a bill of collection for $30,990.29 to reimburse VA for a misuse of travel funds.
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8 We recommend that the VA Chief of Staff ensure that Mr. Moore's time and attendance between March and October 2012 is corrected and that he is charged the appropriate annual and sick leave for that time.
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9 We recommend that the VA Chief of Staff ensure that the total amount paid to Mr. Moore for the 20 instances that he was absent without authorization be determined and that Mr. Moore is issued a bill of collection for that amount, since he cannot receive pay for the time that he was absent without authorization.
Closure Date:
10 We recommend that the VA Chief of Staff ensure that the Information Security Officer with oversight for Mr. Moore's VA-issued equipment, to include his laptop and cellular telephone, examine that equipment to remove any unauthorized software and/or content.
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11 We recommend that the VA Chief of Staff ensure that all VACI employees, to include any detailed or assigned to VACI from other organizations, receive refresher training on Federal travel regulations and VA travel policy.
Closure Date:
12 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take concerning the prohibited personnel practice and Mr. Moore's promotion.
Closure Date:
13 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Holly.
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14 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Buchanan.
Closure Date:
15 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Thompson.
Closure Date:
16 We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Carroll.
Closure Date:
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| 12-02910-80 | Audit of VA's Hearing Aid Services | Audit | ||
1 We recommend the Under Secretary for Health develop a plan to implement productivity standards and staffing levels for audiology clinics.
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2 We recommend the Principal Executive Director of Office of Acquisition, Logistics, and Construction determine the appropriate staffing levels based on workload at the Denver Acquisition and Logistics Center's repair lab to help meet the timeliness standard for repair.
Closure Date:
3 We recommend the Principle Executive Director of Office of Acquisition, Logistics, and Construction ensure Denver Acquisition and Logistics Center management establish controls to timely track and monitor hearing aids from the date received for repair.
Closure Date:
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| 13-03648-75 | Combined Assessment Program Review of the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that members from Anesthesia and Surgery Services consistently attend Transfusion Review Committee meetings and that attendance records be available to support membership and attendance.
Closure Date:
2 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
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3 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.
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4 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.
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5 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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| 13-03747-76 | Healthcare Inspection – Environment of Care Deficiencies in the Operating Room, VA Connecticut Healthcare System, West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director strengthen policies and procedures related to the operating room environment of care to be consistent with recognized industry standards.
2 We recommended that the Facility Director develop and implement policies and procedures to address management of infectious patients in the operating room; Heating, Ventilation, and Air Conditioning system preventive maintenance; and insect control in the operating room.
3 We recommended that the Facility Director reassess Environmental Management Services staffing needs in the operating room and assign personnel requisite to the workload on each shift.
4 We recommended that the Facility Director ensure that Environmental Management Services staff and supervisors receive training on operating room environment of care requirements, especially terminal cleaning.
5 We recommended that the Facility Director implement procedures to monitor the operating room environment of care and to address identified deficiencies.
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| 13-03626-73 | Combined Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the PRC consistently submit quarterly summary reports to the Clinical Management Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that soiled utility rooms are secured and that compliance be monitored.
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3 We recommended that processes be strengthened to ensure that construction sites are secured when unattended and that compliance be monitored.
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4 We recommended that canteen/cafeteria employees be educated on hand hygiene requirements and that compliance be monitored.
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5 We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training.
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6 We recommended that processes be strengthened to ensure that automated external defibrillator checks are conducted daily and documented and that compliance be monitored.
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7 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.
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8 We recommended that the facility establish an interprofessional pressure ulcer committee.
Closure Date:
9 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:
10 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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| 13-04331-63 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Boise VA Medical Center, Boise, Idaho | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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2 We recommended that CBOC/PCC staff provide education and counseling for patients with a positive alcohol screen and drinking levels above NIAAA limits.
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3 We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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4 We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
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5 We recommended that CBOC/PCC RN Care Managers receive MI interviewing and health coaching training within 12 months of appointment to PACT.
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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.
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7 We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
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8 We recommended that staff document the evaluation of each patient’s level of understanding for the medication education.
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| 13-03178-70 | Healthcare Inspection – Alleged Lapses in Communication and Poor Quality of Care, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that a process is in place to assure that patient information is shared with patients, families, and significant others in an appropriate manner that protects patient privacy.
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2 We recommended that the Facility Director ensure that processes be strengthened for inventory, documentation, storage, and retrieval of patient belongings, and that compliance is monitored.
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| 13-03624-58 | Healthcare Inspection – Alleged Patient Safety Concerns in the Operating Room, VA Maine Healthcare System, Augusta, Maine | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop and implement a master staffing plan for the operating room based on Association of Perioperative Registered Nurses recommendations to ensure adequate coverage and support for operating room staff.
Closure Date:
2 We recommended that the Facility Director ensure that the Surgical Work Group and Operating Room Committee are implemented and functioning in accordance with Veterans Health Administration and local policies.
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3 We recommended that the Facility Director implement the recommendations made during a protected Veterans Health Administration Surgical Program review.
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| 13-04242-61 | Combined Assessment Program Review of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Operative/Invasive Procedures Committee meet monthly, include the COS as a member, and document its review of National Surgical Office reports.
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2 We recommended that processes be strengthened to ensure that infection prevention risk assessments prioritize risks for acquiring and transmitting infections.
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3 We recommended that processes be strengthened to ensure that orders for mammograms are entered in CPRS and that compliance be monitored.
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4 We recommended that processes be strengthened to ensure that clinicians screen patients for tetanus vaccinations at clinic visits.
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5 We recommended that processes be strengthened to ensure that clinicians document all required vaccine administration elements and that compliance be monitored.
Closure Date:
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| 13-04240-60 | Combined Assessment Program Review of the White River Junction VA Medical Center, White River Junction, Vermont | 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.
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2 We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the CEB.
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3 We recommended that the local observation bed policy be revised to include how the responsible service and provider are determined and that each observation patient must have a focused goal for the period of observation.
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4 We recommended that the Operative and Invasive Procedure Committee meet monthly and include the Chief of Staff as a member.
Closure Date:
5 We recommended that processes be strengthened to ensure that Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
Closure Date:
6 We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
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7 We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
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8 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.
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9 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale daily and at discharge and develop interprofessional treatment plans and that compliance be monitored.
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10 We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer stages, risk scale scores, and wound improvement or deterioration, including wound characteristics, from the time of admission to the time of discharge.
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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15303