Recommendations
2132
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01976-312 | Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut | 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.
2 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that the data collected from resuscitation episodes are critically analyzed.
3 We recommended that the facility implement a quality control policy for scanning.
4 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
5 We recommended that processes be strengthened to ensure that EOC Committee minutes include results of EOC rounds, identify who is responsible for correcting environmental deficiencies, and track deficiencies to closure.
6 We recommended that processes be strengthened to ensure that restrooms and showers on inpatient units are clean.
7 We recommended that processes be strengthened to ensure that public restrooms and elevators are clean, that public restrooms are free from environmental safety hazards, and that automatic door opening switches in all public restrooms are operational.
8 We recommended that managers initiate actions to address the four identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
9 We recommended that processes be implemented to ensure that quarterly trend reports are provided timely to the facility Director and that trending and analysis of the data includes all elements required by VHA policy.
10 We recommended that processes be strengthened to ensure that all required non-pharmacy and pharmacy areas with CS are inspected monthly.
11 We recommended that processes be strengthened to ensure that inspectors validate 2 transfers of CS from 1 storage area to another area and that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled.
12 We recommended that the PCCT includes a dedicated administrative support person and psychologist or other mental health provider.
13 We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
14 We recommended that the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
15 We recommended that processes be strengthened to ensure that acute care staff accurately document PU location, stage, risk scale score, and date acquired.
16 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections for patients at risk for or with PUs and consistently revise prevention plans if the patients’ risk levels change.
17 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.
18 We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the PU risk scale, how to conduct a complete skin assessment, and how to accurately document findings.
19 We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection.
20 We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.
21 We recommended that nurse managers reassess the target nursing hours per patient day for the medical intensive care unit to more accurately plan for staffing and evaluate the actual staffing provided.
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| 12-01702-303 | Combined Assessment Program - Evaluation of Polytrauma Care in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health ensures that VHA performs a detailed analysis of workload and resource use to determine whether there is continued need for the numbers of sites at the current levels and whether changes in the requirements for dedicated polytrauma resources are needed.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that Level IV sites performing comprehensive TBI evaluations have approved alternate plans.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently complete TBI evaluations within 30 days of positive screens and that compliance is monitored.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that the case management process meets requirements and that compliance is monitored.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that staff caring for polytrauma patients have the documented competencies required for caring for polytrauma patients and that compliance is monitored.
Closure Date:
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| 13-00026-306 | Community Based Outpatient Clinic Reviews at VA Maryland Health Care System, Baltimore, Maryland | 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 tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
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| 13-02312-304 | Combined Assessment Program Review of the Cheyenne VA Medical Center, Cheyenne, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that
the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
2 We recommended that all required members participate in
Transfusion Review/Lab Utilization Review Committee meetings.
Closure Date:
3 We recommended that the facility establish a policy for pressure
ulcer prevention, establish an interprofessional pressure ulcer committee, and ensure that the interprofessional pressure ulcer committee reports program data to facility executive leadership.
Closure Date:
4 We recommended that processes be strengthened to ensure that
acute care staff perform and document a complete skin inspection and risk scale at
discharge and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and/or risk scale score for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
6 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:
7 We recommended that the facility establish patient/caregiver and staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
8 We recommended that the facility fully implement the nurse staffing methodology.
Closure Date:
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| 13-01550-286 | Inspection of VA Regional Office St. Paul, Minnesota | Review | ||
1 We recommend the St. Paul VA Regional Office Director conduct a review of the 299 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the St. Paul VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of that training.
Closure Date:
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| 13-02257-294 | Inspection of VA Regional Office Togus, Maine | Review | ||
1 We recommend the Togus VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examinations to obtain the evidence required to support traumatic brain injury evaluations.
Closure Date:
2 We recommend the Togus VA Regional Office Director develop and implement a plan to ensure staff completely and timely address all required elements of Systematic Analyses of Operations.
Closure Date:
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| 12-04631-313 | Healthcare Inspection - Gastroenterology Consult Delays, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina | Hotline Healthcare Inspection | ||
1 We recommend that, in accordance with the Administrative Investigation Board conclusions and recommendations, Veterans Integrated Service Network leaders take appropriate action in relationship to leadership deficits contributing to the gastroenterology consult backlog.
Closure Date:
| ||||
| 12-00181-299 | Audit of VBA's Pension Payments | Audit | ||
1 We recommended the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements procedures that ensure continued veteran and beneficiary eligibility.
Closure Date:
2 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements a plan to reduce the amount of underpayments and overpayments due to changes in income and dependency.
Closure Date:
3 We recommend the Under Secretary for Benefits implement the use of the enhanced interagency exchange agreements with the Internal Revenue Service and Social Security Administration to reduce delays in verifying veteran and beneficiary reported income.
Closure Date:
4 We recommended the Under Secretary for Benefits establish a matching program with Medicaid to automatically identify veterans and beneficiaries that require nursing home adjustments.
Closure Date:
5 We recommend the Under Secretary for Benefits ensure the Pension Management Centers clearly outline processing priorities in their workload management plans.
Closure Date:
6 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements its plan to revise triage procedures and establish processing lanes to ensure prompt screening and routing of claims.
Closure Date:
7 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service corrects the duplicate records identified in this audit.
Closure Date:
8 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service requests an additional data test be added to their current series of data tests that would identify claimant records with similar or same names under the same
file number.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $502,000,000
Total: $502,000,000
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| 13-01351-296 | Healthcare Inspection – Alleged Sterile Processing Service Deficiencies, VA Puget Sound Health Care System, Seattle, Washington | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that Sterile Processing Service has a process in place to identify single-use devices and mitigate the risk of single-use devices being resterilized.
Closure Date:
2 We recommended that the System Director ensure that processes be strengthened to ensure that Sterile Processing Service staff competency records are well organized and that managers are able to readily determine the current competence of each person on each task.
Closure Date:
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| 12-04326-275 | Inspection of VA Regional Office Muskogee, Oklahoma | Review | ||
1 We recommend the Muskogee VA Regional Office Director conduct a review of the 304 temporary 100 percent disability evaluations remaining from our inspection universe.
Closure Date:
2 We recommend the Muskogee VA Regional Office Director provide refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of the training.
Closure Date:
3 We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure accurate second-signature reviews of traumatic brain injury claims.
Closure Date:
4 We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure Rating Veterans Service Representatives correctly address Gulf War veterans' entitlement to mental health treatment as required.
Closure Date:
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15353