OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Oversight Reports

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the facility ensure the designated quality, safety, and value committee meets quarterly and is chaired or co-chaired by the Facility Director.

No. 2   to Veterans Health Administration (VHA)

We recommended that the facility revise the policy/by-laws to specify a frequency for clinical managers to review practitioners’ Ongoing Professional Practice Evaluation data every 6 months.

No. 3   to Veterans Health Administration (VHA)

We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that the facility consistently evaluate actions for effectiveness in the Clinical Executive Committee and Performance Improvement Board and that facility managers monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that facility managers ensure horizontal surfaces, ventilation grills, and floors in patient care areas are clean and monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the standard operating procedure for the retrograde cholangiopancreatography endoscope is consistent with the manufacturer’s instructions for use.

No. 11   to Veterans Health Administration (VHA)

We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive competencies at orientation and annually for the types of reusable medical equipment they reprocess.

No. 12   to Veterans Health Administration (VHA)

We recommended that the facility revise the policy for anticoagulation management to include addressing no shows and patient noncompliance and minimizing loss to follow-up.

No. 13   to Veterans Health Administration (VHA)

We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.

No. 14   to Veterans Health Administration (VHA)

We recommended that clinical managers complete semiannual competency assessments for employees actively involved in the anticoagulant program and that facility managers monitor compliance.

No. 15   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility.

No. 16   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in transfer documentation and that facility managers monitor compliance.

No. 17   to Veterans Health Administration (VHA)

We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.

No. 18   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.

No. 19   to Veterans Health Administration (VHA)

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. 20   to Veterans Health Administration (VHA)

We recommended that the facility report and trend the use of reversal agents in moderate sedation cases and process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.

No. 21   to Veterans Health Administration (VHA)

We recommended that the VA Police Officer, Patient Safety Manager and/or Risk Manager, and Patient Advocate consistently attend Disruptive Behavior Committee meetings.

No. 22   to Veterans Health Administration (VHA)

We recommended that the facility collect and analyze data from disruptive or violent behavior incidents.

No. 23   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.

No. 24   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

No. 25   to Veterans Health Administration (VHA)

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. 26   to Veterans Health Administration (VHA)

We recommended that all doors on the Domiciliary Care for Homeless Veterans Program unit other than the main point of entry be locked and alarmed.

No. 27   to Veterans Health Administration (VHA)

We recommended that the facility fully implement the nurse staffing methodology and conduct annual reassessments.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.

No. 2   to Veterans Health Administration (VHA)

We recommended that facility managers ensure all fire extinguishers are inspected monthly and marked with the correct date and monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that employees document when they access information technology network rooms by using the visitor logs and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive annual competencies for the types of reusable medical equipment they reprocess.

No. 5   to Veterans Health Administration (VHA)

We recommended that hemodialysis unit employees wear gloves when handling patient equipment and that the hemodialysis unit manager monitors compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating warfarin treatment.

No. 7   to Veterans Health Administration (VHA)

We recommended that for employees actively involved in the anticoagulant program, clinical managers include in the competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility and that facility managers monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and of medical and behavioral stability in transfer documentation and that facility managers monitor compliance.

No. 11   to Veterans Health Administration (VHA)

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. 12   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.

No. 13   to Veterans Health Administration (VHA)

We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.

No. 14   to Veterans Health Administration (VHA)

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 for community nursing home oversight and monitor compliance.

No. 15   to Veterans Health Administration (VHA)

We recommended that the facility update its policy on the community nursing home program to include all elements required by Veterans Health Administration policy.

No. 16   to Veterans Health Administration (VHA)

We recommended that a VA physician order or approve all therapies that are at VA expense.

No. 17   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the community nursing home program office scans existing paper health records into electronic health records and develops a process to scan new records as they are received.

No. 18   to Veterans Health Administration (VHA)

We recommended that the facility update its policy on preventing and managing disruptive and violent behavior.

No. 19   to Veterans Health Administration (VHA)

We recommended that the VA Police Officer and the Patient Advocate consistently attend Disruptive Behavior Committee meetings.

No. 20   to Veterans Health Administration (VHA)

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 training is documented in employee training records.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

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. 2   to Veterans Health Administration (VHA)

We recommended that facility managers ensure floors and rolling equipment in patient care areas are clean and in good repair and monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that the facility review quality assurance data for the anticoagulation management program monthly at Pharmacy and Therapeutics Committee meetings and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulants.

No. 5   to Veterans Health Administration (VHA)

We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that the laboratory director develop and implement a process to ensure employee competency for point-of-care testing with glucometers.

No. 7   to Veterans Health Administration (VHA)

We recommended that the laboratory director ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.

No. 9   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.

No. 11   to Veterans Health Administration (VHA)

We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.

No. 12   to Veterans Health Administration (VHA)

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.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the facility consistently take action when data analyses indicated problems or opportunities for improvement and evaluate the actions for effectiveness in peer review and Focused Professional Practice Evaluations and that facility managers monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the facility Chief of Staff ensure that all required practitioners are designated as members of the medical staff.

No. 3   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the access log for the Huntingdon County VA Clinic information technology network room includes all required elements to document access and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Huntingdon County VA Clinic and that facility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the facility designate a physician anticoagulation program champion.

No. 6   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility.

No. 7   to Veterans Health Administration (VHA)

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. 8   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.

No. 9   to Veterans Health Administration (VHA)

We recommended that facility managers ensure integration of the community nursing home program into its quality improvement program.

No. 10   to Veterans Health Administration (VHA)

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 for community nursing home oversight and that facility managers monitor compliance.

No. 11   to Veterans Health Administration (VHA)

We recommended that a VA physician order or approve all therapies that are at VA expense.

No. 12   to Veterans Health Administration (VHA)

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 training is documented in employee training records.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

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. 2   to Veterans Health Administration (VHA)

We recommended that facility managers ensure clean bed frames in patient care areas and monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.

No. 4   to Veterans Health Administration (VHA)

We recommended that the facility designate a physician anticoagulation program champion.

No. 5   to Veterans Health Administration (VHA)

We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.

No. 6   to Veterans Health Administration (VHA)

We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility.

No. 8   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”

No. 11   to Veterans Health Administration (VHA)

We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.

No. 12   to Veterans Health Administration (VHA)

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 for community nursing home oversight and that facility managers monitor compliance.

No. 13   to Veterans Health Administration (VHA)

We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.

No. 14   to Veterans Health Administration (VHA)

We recommended that the facility’s Disruptive Behavior Committee include a senior clinician chair and the Patient Safety Manager and/or Risk Manager and that the Patient Advocate consistently attend Disruptive Behavior Committee meetings.

No. 15   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.

No. 16   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

No. 17   to Veterans Health Administration (VHA)

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. 18   to Veterans Health Administration (VHA)

We recommended that that the Medical Executive Committee discuss and document its approval of the use of another facility’s physicians for teledermatology services.

No. 19   to Veterans Health Administration (VHA)

We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility.

No. 3   to Veterans Health Administration (VHA)

We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers consistently include date of transfer and documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that the facility trend the use of reversal agents in moderate sedation cases, that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events, and that facility managers monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that providers include the history of previous adverse experiences with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that clinical managers ensure employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care and that training is documented and monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that the facility establish a Community Nursing Home Oversight Committee.

No. 10   to Veterans Health Administration (VHA)

We recommended that facility managers ensure clinical visits occur within the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.

No. 11   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.

No. 12   to Veterans Health Administration (VHA)

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. 13   to Veterans Health Administration (VHA)

We recommended that the Facility Director immediately remove unauthorized employees’ access to the medication room, evaluate access for all medication rooms within the facility, and take corrective action to meet Veterans Health Administration requirements.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Quality, Safety, and Value Committee be consistently chaired or co-chaired by the Facility Director.

No. 2   to Veterans Health Administration (VHA)

We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that facility managers ensure carpets and tile floors in patient care areas are clean and monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.

No. 9   to Veterans Health Administration (VHA)

We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug-to-drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.

No. 11   to Veterans Health Administration (VHA)

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 for community nursing home oversight and monitor compliance.

No. 12   to Veterans Health Administration (VHA)

We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior and a Disruptive Behavior Committee/Board.

No. 13   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

No. 14   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.

No. 15   to Veterans Health Administration (VHA)

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. 16   to Veterans Health Administration (VHA)

We recommended that clinicians enter orders for mammograms in the Computerized Patient Record System and that clinical managers monitor compliance.

No. 17   to Veterans Health Administration (VHA)

We recommended that clinicians screen patients for tetanus vaccinations at clinic visits and that clinical managers monitor compliance.

No. 18   to Veterans Health Administration (VHA)

We recommended that clinicians document all required vaccine administration elements and that clinical managers monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

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. 2   to Veterans Health Administration (VHA)

We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that facility managers ensure air conditioner and steam/heat ventilation grills in the Emergency Department are clean and monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that facility managers ensure refrigerators in patient nourishment kitchens do not contain unlabeled food items and monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the facility implement a policy for cleaning, disinfecting, and sterilizing reusable medical equipment.

No. 6   to Veterans Health Administration (VHA)

We recommended that facility managers ensure standard operating procedures for the colonoscope, esophagogastroduodenoscope, and duodenoscope are consistent with the manufacturers' instructions for use.

No. 7   to Veterans Health Administration (VHA)

We recommended that hemodialysis unit employees secure chemicals when not in use and that the hemodialysis unit manager monitors compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that providers consistently complete VA form 10-2649A or use a properly templated inter-facility transfer note template for patients transferred out of the facility and that facility managers monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in VA Form 10-2649A, Inter-Facility Transfer Form, and that facility managers monitor compliance.

No. 11   to Veterans Health Administration (VHA)

We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitor compliance.

No. 12   to Veterans Health Administration (VHA)

We recommended that sending nurses document transfer assessments/notes for patients transferred out of the facility and that facility managers monitor compliance.

No. 13   to Veterans Health Administration (VHA)

We recommended that facility managers ensure that for emergent transfers, provider transfer notes include a statement of patient stability for transfer and that facility managers monitor compliance.

No. 14   to Veterans Health Administration (VHA)

We recommended that employees perform quality control on glucometers in accordance with the facility's policy/standard operating procedure and the manufacturer's recommendations and that facility managers monitor compliance.

No. 15   to Veterans Health Administration (VHA)

We recommended that providers include history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.

No. 16   to Veterans Health Administration (VHA)

We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.

No. 17   to Veterans Health Administration (VHA)

We recommended that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and that facility managers monitor compliance.

No. 18   to Veterans Health Administration (VHA)

We recommended that clinical employees discharge outpatients from the recovery area with orders given by a qualified provider or according to criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.

No. 19   to Veterans Health Administration (VHA)

We recommended that the facility integrate the community nursing home program into its quality improvement program.

No. 20   to Veterans Health Administration (VHA)

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 for community nursing home oversight and monitor compliance.

No. 21   to Veterans Health Administration (VHA)

We recommended that facility managers ensure Disruptive Behavior Committee discussion of patients' disruptive or violent behavior and entry of a progress note into the patients' electronic health records.

No. 22   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

No. 23   to Veterans Health Administration (VHA)

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, ensure training is documented in employee training records, and monitor compliance.

No. 24   to Veterans Health Administration (VHA)

We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections and that program managers monitor compliance.

No. 25   to Veterans Health Administration (VHA)

We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document every 2-hour rounds of all public spaces, daily bed checks, and daily resident room inspections for unsecured medications and that program managers monitor compliance.

No. 26   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the Substance Abuse Residential Rehabilitation Treatment Program unit's non-main entry door is alarmed at all times and that program managers monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, corrective actions taken to address identified deficiencies, and tracking of corrective actions to closure.

No. 2   to Veterans Health Administration (VHA)

We recommended that the facility implement actions to address all high-risk areas and ensure Infection Control Committee minutes document those actions and the follow-up on actions implemented to address identified problems.

No. 3   to Veterans Health Administration (VHA)

We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.

No. 5   to Veterans Health Administration (VHA)

We recommended that the facility review quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that facility managers ensure that clinicians consistently obtain all required laboratory tests prior to initiating anticoagulation warfarin treatment and that clinicians obtain initial prothrombin/international normalized ratio through laboratory testing.

No. 8   to Veterans Health Administration (VHA)

We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.

No. 11   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.

No. 12   to Veterans Health Administration (VHA)

We recommended that facility managers ensure that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility¿s capacity and monitor compliance.

No. 13   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.

No. 14   to Veterans Health Administration (VHA)

We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.

No. 15   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.

No. 16   to Veterans Health Administration (VHA)

We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.

No. 17   to Veterans Health Administration (VHA)

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 for community nursing home oversight and monitor compliance.

No. 18   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags and ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

No. 19   to Veterans Health Administration (VHA)

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. 20   to Veterans Health Administration (VHA)

We recommended that clinicians provide education and counseling to patients with positive alcohol screens and who reported drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the facility replace missing and stained ceiling tiles in patient care areas and that facility managers monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that facility managers ensure standard operating procedures for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with the manufacturers’ instructions for use.

No. 3   to Veterans Health Administration (VHA)

We recommended that Sterile Processing Service employees document positive quality control testing results for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography in a manner that allows tracking of actions taken and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the facility provide patients with a direct telephone number for anticoagulation-related calls during normal business hours and define a process for anticoagulation calls outside normal business hours.

No. 5   to Veterans Health Administration (VHA)

We recommended that the facility designate a physician anticoagulation program champion.

No. 6   to Veterans Health Administration (VHA)

We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy and that facility managers monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility.

No. 8   to Veterans Health Administration (VHA)

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. 9   to Veterans Health Administration (VHA)

We recommended that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that the facility note the absence of adverse events in Operative and Invasive Procedure Committee reports and that facility managers monitor compliance.

No. 11   to Veterans Health Administration (VHA)

We recommended that clinical managers ensure clinical employees who perform or assist with moderate sedation procedures have current Talent Management System training for the provision of moderate sedation care, ensure the training is documented, and monitor compliance.

No. 12   to Veterans Health Administration (VHA)

We recommended that the facility revise the policy on ensuring correct surgery and invasive procedures to include all elements of the timeout checklist required by Veterans Health Administration Directive 1039.

No. 13   to Veterans Health Administration (VHA)

We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.

No. 14   to Veterans Health Administration (VHA)

We recommended that facility managers ensure social workers conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.

No. 15   to Veterans Health Administration (VHA)

We recommended that the facility revise the workplace violence prevention policy to include required membership for the Disruptive Behavior Committee.

No. 16   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters Patient Record Flags into the electronic health records.

No. 17   to Veterans Health Administration (VHA)

We recommended that the facility implement a process to ensure all surgical deaths are tracked and reviewed by appropriate clinical employees.

No. 18   to Veterans Health Administration (VHA)

We recommended that acute care employees accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that facility managers monitor compliance.

No. 19   to Veterans Health Administration (VHA)

We recommended that clinic employees document in patients’ electronic health records medication reconciliation that includes the newly prescribed fluoroquinolone, patient counseling/education that includes the fluoroquinolone, and evaluation of the patients’ level of understanding of the education.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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