Date Issued
|
Report Number
14-04194-118
All Reports
Date Issued
|
Report Number
14-04386-124
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/22/2015
We recommended that the information technology server closet at the Polk Street VA Annex Clinic is maintained according to information technology safety and security standards.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/19/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/19/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/28/2017
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
|
Report Number
14-04213-115
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility ensure that the Emergency Services Committee physician member consistently attends meetings and participates in code reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/11/2015
We recommended that the Safe Patient Handling Committee track patient handling injury data.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the Medical Record Committee include physician documentation in the review of electronic health record quality.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/21/2015
We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/21/2015
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that facility managers ensure that medications
are secured at all times and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/12/2016
We recommended that the facility conduct and document annual complete system checks of the community living center's elopement prevention system and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility ensure the high-alert/hazardous medication list is available for staff reference on the acute medicine unit and both community living center units.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility ensure nursing staff review monthly inspections of nursing station medication areas.
Date Issued
|
Report Number
14-01708-123
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Facility Director ensure that senior leadership and nursing managers fully implement the VHA Nurse Staffing Methodology Plan as required.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Facility Director ensure that senior leadership and nursing managers fully evaluate the medical intensive care and step down units' patient mix, staffing plan, patterns of floating, physical layout, and unit assignments for opportunities for improvement and take necessary action.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/3/2015
We recommended that the Facility Director ensure that patient incident reporting processes be strengthened so that all patient incidents or safety concerns are reported promptly to the patient safety manager.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the Facility Director ensure that nursing staff perform and document fall risk assessments as required.
Date Issued
|
Report Number
14-04389-106
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period.
No. 2
to Veterans Health Administration (VHA)
We recommended that managers develop and communicate an egress plan for the safety of all patients.
No. 3
to Veterans Health Administration (VHA)
We recommended that processes are strengthened to ensure that women veterans can access gender-specific restrooms without entering public areas.
No. 4
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
to Veterans Health Administration (VHA)
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 8
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Date Issued
|
Report Number
14-04224-107
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that facility managers monitor the recently revised reprivileging process to ensure practitioners have the appropriate skills and training for emergency airway management.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/29/2015
We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/29/2015
We recommended that Medicine Service designate an Automated Data Processing Applications Coordinator.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
Date Issued
|
Report Number
11-04212-127
Date Issued
|
Report Number
14-04378-97
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that clinic staff protect patient-identifiable information on laboratory specimens during transport from the Carmel CBOC to the parent facility.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Date Issued
|
Report Number
14-04223-100
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Executive Quality, Safety, and Value Committee continue to meet and ensure that aggregated data is reviewed, that problems or opportunities for improvement are identified, that specific actions are documented, and that actions are fully implemented and monitored over time.
No. 2
to Veterans Health Administration (VHA)
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Critical Care Committee review each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that the committee consistently collect code data.
No. 4
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly.
No. 5
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
No. 6
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document
does not meet image quality controls and a complete review of scanned documents to ensure readability and retrievability.
No. 7
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
We recommended that the facility conduct contrast reaction drills in the magnetic resonance imaging area and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
We recommended that the facility ensure all designated Level 1 ancillary staff and all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
We recommended that the facility implement a stroke care designation appropriate to its inpatient acute care complexity.
No. 13
to Veterans Health Administration (VHA)
We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
No. 14
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
We recommended that facility managers post stroke guidelines in the Emergency Department and on the intensive care and acute inpatient care units.
No. 16
to Veterans Health Administration (VHA)
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
We recommended that facility managers provide a stroke education program.
No. 18
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 19
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that applicable Nursing Service employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 20
to Veterans Health Administration (VHA)
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
No. 21
to Veterans Health Administration (VHA)
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of scopes of practice and includes all required elements and that facility managers monitor compliance.
Date Issued
|
Report Number
14-04215-99
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that the facility ensure that licensed independent practitioners' folders do not contain licensure verification information.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/13/2015
We recommended that the facility appropriately protect computer monitors from public viewing on the medical and surgical units and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that the facility designate a committee to oversee consult management.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that the Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that Radiology Service revise the computed tomography scan and magnetic resonance imaging on-call policy to require a 30-minute reporting time.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the surgical intensive care unit.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/25/2015
We recommended that Domiciliary Care for Homeless Veterans and Post-Traumatic Stress Disorder Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Date Issued
|
Report Number
14-04211-94
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that facility managers ensure licensed independent practitioners trained to perform airway management are fully privileged.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the facility complete the conversion from the six-part credentialing and privileging folder to the two-part privileging folder.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Emergency Response Committee document review of each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that facility managers ensure public restrooms are free of insects and monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the facility clean and/or repair dirty/damaged wheelchairs in patient care areas or remove them from service.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that facility managers ensure walk-off sticky mats are in place at construction site entrances to minimize dust, ensure site entrances are secured, and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the facility not stock heparin in concentrations of more than 5,000 units per milliliter in patient care areas or document approval by the Chief of Pharmacy to stock in these concentrations.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the facility revise the plan for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the facility revise the stroke policy to address screening for difficulty swallowing and use of the National Institutes of Health Stroke Scale and tracking of its use and that the facility managers fully implement the revised policy.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility collect and report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility comply with Veterans Health Administration directive requirements for exempted facilities, or if the facility plans intubations during emergency responses, they comply with Veterans Health Administration requirements for non-exempted facilities.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the facility ensure a provider with completed emergency airway management privileges or a clinician with completed emergency airway management scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.
Date Issued
|
Report Number
14-05132-90
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility policy addresses outpatient pressure ulcer prevention and treatment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish pressure ulcer committees with appropriate professional representation.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities' pressure ulcer programs define requirements for employee training regarding pressure ulcer risk assessment, skin assessment and management, and documentation of skin assessment findings and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians revise pressure ulcer prevention plans when patients' risk levels change and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document patient/caregiver pressure ulcer education and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document skin inspections and Braden scales daily during hospitalization, including the day of discharge, and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish processes to monitor consistency in documentation of pressure ulcer stage, location, date acquired, and risk scale score and take appropriate actions to address inconsistencies.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians document wound care follow-up plans for patients discharged with unhealed pressure ulcers and that the facility provides needed supplies.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees secure medications stored in patients' rooms.
Date Issued
|
Report Number
14-04219-98
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility create/designate a committee to oversee consult management.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the Medicine, Mental Health, Surgical, and Rehabilitation Services' Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that scanned magnetic resonance imaging documents are accurate and complete and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility revise the emergency airway management policy to include demonstration of competency by both direct and video laryngoscopy.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that facility managers ensure the Psychosocial Residential Rehabilitation Treatment Program environment is clean and monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 8/3/2015
We recommended that the facility ensure that Psychosocial Residential Rehabilitation Treatment Program stained ceiling tiles are replaced, damaged baseboards and chipped wall tiles are repaired or replaced, and the emergency exit door is repaired.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that clinicians document all required vaccination administration elements and that facility managers monitor compliance.
Date Issued
|
Report Number
15-00430-103
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the Interim Under Secretary for Health continue to develop and implement staffing models for critical need occupations.
Date Issued
|
Report Number
14-00875-112
Date Issued
|
Report Number
14-04221-91
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that clinicians consistently complete final peer reviews within required timeframes and obtain written requests for extensions approved by the Facility Director and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that the Cardiopulmonary Resuscitation Committee fully review each code episode.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Surgical Work Group meet monthly and include the Chief of Staff as a member.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the quality control policy for scanning include all required elements.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that Infection Control Committee meeting minutes reflect implementation of actions to address high-risk areas and provide sufficient follow-up actions to address identified problems.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that facility managers ensure all designated critical care nurses receive hazardous material training and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that facility managers ensure all negative pressure control systems in isolation rooms are functional and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure all crash cart medications are current and daily crash cart inspections are consistently documented and include all required elements and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that facility managers ensure designated employees receive annual automated dispensing machine training and competency assessment and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that requesters consistently select the proper consult title and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility develop and implement an acute ischemic stroke policy that addresses all required items.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 2/23/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 11/3/2015
We recommended that facility managers post stroke guidelines in all areas where patients may present with stroke symptoms.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 2/23/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility collect and report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that facility managers ensure that nursing staff who perform 12-lead electrocardiograms have a current competency assessment and validation included in their competency checklists and have competency assessment and validation documentation completed.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists for employees on the post-anesthesia care unit.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility revise the emergency airway management policy to include all required Veterans Health Administration elements.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and a written exam and that facility managers monitor compliance.
No. 26
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
No. 27
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
Date Issued
|
Report Number
14-04218-92
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
Date Issued
|
Report Number
13-03324-85
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 3/31/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish procedures to ensure the Office of Product Development completes all required Planning Reviews (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 2
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure personnel performing Compliance Reviews assess the accuracy and reasonableness of cost information reported on the Project Management Accountability System Dashboard (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 3
to Information and Technology (OIT)
Closure Date: 3/20/2018
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure hiring actions are completed by acquiring the vacant Federal employee positions in the Project Management Accountability System Business Office (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 4
to Information and Technology (OIT)
Closure Date: 1/22/2015
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, not exercise future options of the task order used to augment Project Management Accountability System Business Office staffing once hiring actions have been completed.
No. 5
to Information and Technology (OIT)
Closure Date: 3/31/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete modification of the Project Management Accountability System Dashboard so that it maintains a complete audit trail of baseline data by including planned, revised, and actual figures for project life-cycle and increment costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 6
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete development and implementation of a sound methodology to capture and report planned and actual total project and increment level costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 7
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure project managers capture and report reliable cost data and maintain adequate audit trails to support how the cost information reported on the Project Management Accountability System Dashboard was derived in the interim until actions to automate budget traceability and shift VA’s IT projects to increment-based contracts are completed (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 8
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, clearly define the term “enhancement of an existing system or its infrastructure” and require Service Delivery and Engineering project teams to track and report costs associated with enhancements on the Project Management Accountability System Dashboard.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,400,000.00
Date Issued
|
Report Number
14-04451-88
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/11/2015
We recommended that managers maintain a clean and functioning environment of care at the Peoria CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/28/2015
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Peoria CBOC.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/22/2015
We recommended that the information technology server closet at the Peoria CBOC is maintained according to information technology safety and security standards.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/28/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/28/2015
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Date Issued
|
Report Number
14-04382-86
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/19/2015
We recommended that fire drills are performed every 12 months at the Brainerd CBOC.