Recommendations
2132
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01445-271 | Inspection of VA Regional Office Milwaukee, Wisconsin | Review | ||
1 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
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| 13-01670-269 | Combined Assessment Program Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that VA Police conduct annual physical security surveys of the pharmacy areas and that any identified deficiencies be corrected.
Closure Date:
2 We recommended that processes be strengthened to ensure that the PCCT includes an administrative support person and a dedicated psychologist or other MH professional.
Closure Date:
3 We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
4 We recommended that the facility pressure ulcer policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer was acquired 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 provide and document recommended pressure ulcer interventions and that compliance be monitored.
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 that compliance be monitored.
Closure Date:
8 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:
9 We recommended that nursing managers monitor the staffing methodology that was implemented in December 2012.
Closure Date:
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| 13-01675-266 | Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the PCCT includes a 0.25 full-time employee equivalent psychologist or other mental health provider.
Closure Date:
2 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:
3 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, assessments for change in condition, and/or revisions to prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
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| 13-00899-261 | Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired LIPs are consistently initiated and that results are consistently reported to the MEC.
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
3 We recommended that processes be strengthened to ensure that patient care areas and furnishings are clean and that compliance be monitored.
4 We recommended that processes be strengthened to ensure that inpatient rooms and ED medical equipment are consistently terminally cleaned and that compliance be monitored.
5 We recommended that processes be strengthened to ensure that OR employees who perform IUS receive initial training.
6 We recommended that processes be strengthened to ensure that weekly inventories of automated dispensing machines are consistently conducted and that compliance be monitored.
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated nursing representative.
9 We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
10 We recommended that processes be strengthened to ensure that acute care staff perform and document a skin inspection and risk scale prior to discharge and that compliance be monitored.
11 We recommended that processes be strengthened to ensure that acute care staff accurately document PU location, stage, risk scale score, and data acquired and that compliance be monitored.
12 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections and risk scales for patients at risk for or with PUs and that compliance be monitored.
13 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.
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| 13-00670-265 | Healthcare Inspection - Review of Circumstances Leading to a Pause in Providing Inpatient Care, VA Northern Indiana Healthcare System, Fort Wayne, Indiana | Hotline Healthcare Inspection | ||
1 We recommended that VHA develop policy for guidance when major clinical services are paused at a VA facility.
Closure Date:
2 We recommended that the VISN Director ensure that a review of the facility ICU level of care and support services is completed to determine the appropriate designation.
Closure Date:
3 We recommended that the VISN Director ensure that qualified clinical staff are available to provide care.
Closure Date:
4 We recommended that the VANIHCS Director ensure that efforts continue to recruit qualified staff for vacant leadership positions.
Closure Date:
5 We recommended that the VANIHCS Director ensure that nurse competencies are consistently completed and validated annually.
Closure Date:
6 We recommended that the VANIHCS Director ensure that the facility fully implement the nurse staffing methodology and complete all required steps.
Closure Date:
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| 13-01987-263 | Healthcare Inspection - Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.
Closure Date:
2 We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.
Closure Date:
3 We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
Closure Date:
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| 13-01189-267 | Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
Closure Date:
2 We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
Closure Date:
3 We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
Closure Date:
4 We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Closure Date:
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| 13-00696-254 | Healthcare Inspection - Follow-Up Assessment of Radiation Therapy, VA Long Beach Healthcare System, Long Beach, California | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health ensure that repeated deficiencies in the documentation of patient care are addressed and do not persist.
Closure Date:
2 We recommended that the VISN Director ensure that complications of radiation therapy that are managed at referring facilities are reported to the facility where radiation therapy was provided.
Closure Date:
3 We recommended that the VISN Director require that the facility Director ensure that radiation therapists adhere to local policy when shifts in the field of delivered radiation occur.
Closure Date:
4 We recommended that the VISN Director require that the facility Director ensure that adverse events in the Radiation Oncology department are consistently reported to facility managers as specified in the facility’s action plan in response to the 2011 OIG report.
Closure Date:
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| 13-00368-244 | Inspection of VA Regional Office Waco, Texas | Review | ||
1 We recommend the Waco VA Regional Office Director conduct a review of the 795 temporary 100 percent disability evaluations remaining from the data we used to perform the inspection and take appropriate action.
Closure Date:
2 We recommend the Waco VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of the training.
Closure Date:
3 We recommend the Waco VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration policy requiring second-signature review of each traumatic brain injury claim processed.
Closure Date:
4 We recommend that the Waco VA Regional Office Director develop and implement a plan to ensure staff follow Veterans Benefits Administration policy in including recommendations for identified problems in their Systematic Analyses of Operations.
Closure Date:
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| 13-01988-253 | Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the System Director consult with Regional Counsel to determine if a disclosure of the events related to the patient's episode of acute renal failure, as discussed in this report, is indicated.
Closure Date:
2 We recommended that the System Director ensure that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.
Closure Date:
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15353