Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00026-327 | Community Based Outpatient Clinic Reviews at Chalmers P. Wylie Ambulatory Care Center, Columbus, OH | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
4 We recommended that managers develop a local policy for MH emergencies that reflects the CBOC’s capability and that staff is trained in the procedural steps of the MH emergency plan.
Closure Date:
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| 13-01855-336 | Healthcare Inspection – Quality of Care Issues, Erie VA Medical Center, Erie, PA, and VA Pittsburgh Healthcare System, Pittsburgh, PA | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible disclosure to the surviving family member(s) of the patient.
Closure Date:
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| 13-02316-322 | Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
Closure Date:
2 We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
Closure Date:
4 We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
Closure Date:
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge and that compliance be monitored.
Closure Date:
12 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:
13 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, and daily monitoring for a change in condition for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff perform and document daily monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
Closure Date:
15 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:
16 We recommended that the facility establish staff pressure ulcer education requirements and that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
Closure Date:
17 We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
Closure Date:
18 We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
20 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
21 We recommended that processes be strengthened to ensure that all designated employees complete respirator fit testing and that compliance be monitored.
Closure Date:
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| 13-00026-316 | Community Based Outpatient Clinic Reviews at Sheridan VA Healthcare System, Sheridan, WY | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that MSDS are kept current at the Casper and Riverton CBOCs and that staff is trained in accessing MSDS for hazardous chemicals in the clinical area at the Casper CBOC.
Closure Date:
3 We recommended that managers ensure all exit routes are clearly identified at the Riverton CBOC.
Closure Date:
4 We recommended that testing of the panic alarm system is documented at the Casper and Riverton CBOCs.
Closure Date:
5 We recommended that the Chief of OI&T implements required measures at the Casper CBOC.
Closure Date:
6 We recommended that EOC deficiencies are tracked, trended, and corrected at the Casper and Riverton CBOCs.
Closure Date:
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| 12-03887-319 | Healthcare Inspection – Inadequate Staffing and Poor Patient Flow in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop action plans that address emergency department patient flow and length of stay, including specialty bed access.
Closure Date:
2 We recommended that the Facility Director develop an emergency department staffing policy that includes a contingency plan for additional physician and nurse staffing when patient care demands exceed available staffing resources.
Closure Date:
3 We recommended that the Facility Director ensure that data collection and the reporting process are strengthened.
Closure Date:
4 We recommend that the Facility director ensure that a local diversion policy is developed and implemented.
Closure Date:
5 We recommended that the Facility Director ensure that the patient flow committee meets regularly, membership is reviewed for appropriateness, and follow-up actions are monitored.
Closure Date:
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| 12-02708-301 | Review of Alleged System Duplication in VA’s Virtual Office of Acquisition Software Development Project | Audit | ||
1 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
Closure Date:
2 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $13,000,000
Total: $13,000,000
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| 13-00026-314 | Community Based Outpatient Clinic Reviews at James A. Haley Veterans' Hospital, Tampa, FL | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
3 We recommended that managers ensure that fire drills be completed at the Zephyrhills CBOC as required.
Closure Date:
4 We recommended that managers ensure that signage is installed at the New Port Richey and Zephyrhills CBOCs that clearly identifies fire extinguisher locations.
Closure Date:
5 We recommended that managers ensure that patient privacy is maintained as required at the New Port Richey and Zephyrhills CBOCs.
Closure Date:
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| 13-01498-318 | Healthcare Inspection – An Unexpected Death in a Mental Health Treatment Program, VA New Jersey Health Care System, Lyons, New Jersey | Hotline Healthcare Inspection | ||
1 We recommended that that the Health Care System Director ensures that the Mental Health Residential Rehabilitation Treatment Program complies with local and VHA Mental Health Residential Rehabilitation Treatment Program Safe Medication Management policy requirements.
Closure Date:
2 We recommended that the Health Care System Director ensure that Mental Health Residential Rehabilitation Treatment Program documentation is individualized, timely, and includes required elements.
Closure Date:
3 We recommended that the Health Care System Director ensure that Mental Health leadership provides appropriate professional support for Mental Health Residential Rehabilitation Treatment Program mid-level providers.
Closure Date:
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| 12-04524-321 | Audit of VBA's Veterans' Retraining Assistance Program Participation | Audit | ||
1 We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they must monitor VA students' attendance and grades for satisfactory academic progress.
Closure Date:
2 We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they are required to report VA students' changes in enrollment to VBA within 30 days.
Closure Date:
3 We recommend the Under Secretary for Benefits revise the certifying official handbook to state a veteran's signed statement should not be used as the only means of verifying attendance.
Closure Date:
4 We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they need to accurately report credit hours and class terms in the VA ONline Certification of Enrollment system.
Closure Date:
5 We recommend the Under Secretary for Benefits include language on the Interactive Voice Response scripts to warn veterans of the potential penalty for certifying false enrollment information.
Closure Date:
6 We recommend the Under Secretary for Benefits implement a plan to monitor veterans currently enrolled at the schools that had their approval withdrawn or suspended to ensure they meet Veterans Retraining Assistance Program full-time attendance requirements and are making positive progress towards program completion.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $12,000,000
Total: $12,000,000
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| 13-02599-311 | Healthcare Inspection – Laboratory Delays and Alleged Staff Training Issues, Memphis VA Medical Center, Memphis, Tennessee | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that processes be strengthened to ensure that laboratory turnaround times adhere to facility and VISN 9 expectations.
Closure Date:
2 We recommended that the Facility Director ensure that policies and processes are put in place to establish consistent and appropriate methods for data collection and analysis of laboratory turnaround times.
Closure Date:
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15303