All Reports

Healthcare Inspection – Consult Management Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California
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15-04681-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that providers assign the proper inpatient/outpatient setting and urgency of consults in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff take action within 7 days of a consult request or sooner if clinically indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff timely close or discontinue consults.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2017
We recommended that the Facility Director ensure that staff conduct a review on the quality and timeliness of the cardiology care for Patient 1 as discussed in the report, and take action if appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff monitor and address the care needs of patients on the Homemaker/Home Health Aide services electronic wait list.
Healthcare Inspection—Environment of Care and Other Quality Concerns, Cincinnati VA Medical Center, Cincinnati, Ohio
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16-02094-219

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2017
We recommended that the Facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.
Healthcare Inspection – Community Nursing Home Program Safety Concerns, VA Northern California Healthcare System, Mather, California
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15-01325-205

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director ensure that program staff coordinate mental health appointments, including verifying the necessity, between facility providers and assigned community nursing home physicians prior to scheduling.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that the Facility Director ensure clinical staff report suspected elder abuse within the required timeframe and document the reporting in the patient’s electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2017
We recommended that the Facility Director ensure Non-VA Care Coordination staff timely deliver authorizations for consulted services to contracted community nursing home staff and that facility scheduling staff recognize when patients reside in a community nursing home and coordinate appointments with program or contracted community nursing home staff to ensure timely response to consults.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director require program registered nurses and social workers consistently conduct monthly or quarterly follow-up visits and ensure timely resolution of patient care needs identified in these visits.
Clinical Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania
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16-00571-207

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data twice a year and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers ensure peer reviewers consistently document their use of at least one of the important aspects of care and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that the Patient Safety Manager enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2017
We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility managers ensure all employees receive additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that Residential Recovery Center employees perform and document contraband inspections and rounds of public spaces and that managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.
Healthcare Inspection – Follow-Up Review of Management of Mental Health Consults and Other Access to Care Concerns, VA Maine Healthcare System, Augusta, Maine
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16-00354-201

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2017
We recommended the System Director ensure Mental Health schedulers consistently make direct contact with patients prior to scheduling appointments and that compliance is monitored for a minimum of three months.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2017
We recommended the System Director ensure training and competencies are documented, complete, and up to date for all staff responsible for scheduling Mental Health appointments.
Clinical Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa
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16-00564-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that Environment of Care Council meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure fire extinguisher locations are clearly identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure information technology network room visitor logs contain all the required elements and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that employees store expired medications separately from medications available for administration and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure standard operating procedures for the bronchoscope are consistent with the manufacturer's instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2018
We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that providers perform history and physical examinations within 30 calendar days prior to the moderate sedation procedure and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the facility correct the deficiencies identified for the Mental Health Residential Rehabilitation Treatment Program and that documentation reflects correction actions taken.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure the review of the hazardous materials inventory at the Marshalltown CBOC occurs twice within a 12-month period.
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