jurisdiction: US

text: b" Department of Veterans Affairs\n Office of Inspector General\n\n\n Office of Healthcare Inspections\n\nReport No. 14-00687-155\n\n\n\n\n Combined Assessment Program \n\n Review of the \n\n W.G. (Bill) Hefner VA Medical Center \n\n Salisbury, North Carolina \n\n\n\n\n\nMay 20, 2014\n\n Washington, DC 20420\n\x0cTo Report Suspected Wrongdoing in VA Programs and Operations \n\n Telephone: 1-800-488-8244 \n\n E-Mail: vaoighotline@va.gov\n\n (Hotline Information: www.va.gov/oig/hotline)\n\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n Glossary\n CAP Combined Assessment Program\n CLC community living center\n EHR electronic health record\n EOC environment of care\n facility W.G. (Bill) Hefner VA Medical Center\n FY fiscal year\n MEC Medical Executive Committee\n MH mental health\n MSIT Multidisciplinary Safety Inspection Team\n NA not applicable\n NM not met\n OIG Office of Inspector General\n OPPE Ongoing Professional Practice Evaluation\n PRC Peer Review Committee\n QM quality management\n VHA Veterans Health Administration\n VISN Veterans Integrated Service Network\n\n\n\n\nVA OIG Office of Healthcare Inspections\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n Table of Contents \n\n Page \n\nExecutive Summary ................................................................................................... i\n\n\nObjectives and Scope ................................................................................................ 1\n\n Objectives ............................................................................................................... 1\n\n Scope...................................................................................................................... 1\n\n\nReported Accomplishments...................................................................................... 2\n\n\nResults and Recommendations ................................................................................ 3\n\n QM .......................................................................................................................... 3\n\n EOC ........................................................................................................................ 6\n\n Medication Management......................................................................................... 9\n\n Coordination of Care ............................................................................................... 10\n\n Nurse Staffing ......................................................................................................... 11\n\n Pressure Ulcer Prevention and Management ......................................................... 12\n\n CLC Resident Independence and Dignity ............................................................... 14\n\n Construction Safety................................................................................................. 16\n\n\nAppendixes\n A. Facility Profile .................................................................................................... 18\n\n B. Strategic Analytics for Improvement and Learning ............................................ 19\n\n C. VISN Director Comments .................................................................................. 22\n\n D. Facility Director Comments ............................................................................... 23\n\n E. OIG Contact and Staff Acknowledgments ......................................................... 29\n\n F. Report Distribution ............................................................................................. 30\n\n G. Endnotes ........................................................................................................... 31\n\n\n\n\n\nVA OIG Office of Healthcare Inspections\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n Executive Summary \n\nReview Purpose: The purpose of the review was to evaluate selected health care\nfacility operations, focusing on patient care quality and the environment of care, and to\nprovide crime awareness briefings. We conducted the review the week of\nMarch 24, 2014.\n\nReview Results: The review covered eight activities. We made no\nrecommendations in the following two activities:\n\n\xef\x82\xb7 Medication Management\n\n\xef\x82\xb7 Coordination of Care\n\nThe facility\xe2\x80\x99s reported accomplishments were implementing a robotic surgery system\nand creating a Long-Term Care Center of Excellence.\n\nRecommendations: We made recommendations in the following six activities:\nQuality Management: Ensure the Surgical Work Group meets monthly. Review all\nsurgical deaths. Review the quality of entries in the electronic health record at least\nquarterly. Ensure the Blood Usage Review Committee members from Surgery,\nMedicine, and Anesthesia Services consistently attend meetings. Implement the plan to\ntrack Ongoing Professional Practice Evaluations and present them to the Professional\nStandards Board within the timeframe required by local policy.\n\nEnvironment of Care: Ensure all required staff receive training on identification and\ncorrection of environmental hazards, proper use of the Mental Health Environment of\nCare Checklist, and VA\xe2\x80\x99s National Center for Patient Safety study of suicide on\npsychiatric units. Require that locked mental health unit panic alarm testing includes VA\nPolice response time and that the locked mental health units\xe2\x80\x99 seclusion room floors\nhave a cushioned surface.\n\nNurse Staffing: Monitor the staffing methodology implemented in October 2013.\n\nPressure Ulcer Prevention and Management: Accurately document location, stage, risk\nscale score, and date pressure ulcer acquired for all patients with pressure ulcers.\nProvide and document pressure ulcer education for patients at risk for and with\npressure ulcers and/or their caregivers.\n\nCommunity Living Center Resident Independence and Dignity: Ensure all care\nplanned/ordered assistive eating devices are provided to residents for use during meals.\n\nConstruction Safety: Ensure construction site inspection documentation includes the\ntime of the inspection and the time when corrective actions occurred. Conduct infection\nsurveillance activities related to construction projects, and document this in Infection\nControl Committee minutes.\n\n\nVA OIG Office of Healthcare Inspections i\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nComments\nThe Veterans Integrated Service Network and Facility Directors agreed with the\nCombined Assessment Program review findings and recommendations and provided\nacceptable improvement plans. (See Appendixes C and D, pages 22\xe2\x80\x9328, for the full\ntext of the Directors\xe2\x80\x99 comments.) We will follow up on the planned actions until they are\ncompleted.\n\n\n\n\n JOHN D. DAIGH, JR., M.D. \n\n Assistant Inspector General for \n\n Healthcare Inspections\n\n\n\n\n\nVA OIG Office of Healthcare Inspections ii\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n Objectives and Scope \n\nObjectives\nCAP reviews are one element of the OIG\xe2\x80\x99s efforts to ensure that our Nation\xe2\x80\x99s veterans\nreceive high quality VA health care services. The objectives of the CAP review are to:\n\n \xef\x82\xb7\t Conduct recurring evaluations of selected health care facility operations, focusing\n on patient care quality and the EOC.\n\n \xef\x82\xb7\t Provide crime awareness briefings to increase employee understanding of the\n potential for program fraud and the requirement to refer suspected criminal\n activity to the OIG.\n\nScope\nThe scope of the CAP review is limited. Serious issues that come to our attention that\nare outside the scope will be considered for further review separate from the CAP\nprocess and may be referred accordingly.\n\nFor this review, we examined selected clinical and administrative activities to determine\nwhether facility performance met requirements related to patient care quality and the\nEOC. In performing the review, we inspected selected areas, conversed with managers\nand employees, and reviewed clinical and administrative records. The review covered\nthe following eight activities:\n\n \xef\x82\xb7\t QM\n\n \xef\x82\xb7\t EOC\n\n \xef\x82\xb7\t Medication Management\n\n \xef\x82\xb7\t Coordination of Care\n\n \xef\x82\xb7\t Nurse Staffing\n\n \xef\x82\xb7\t Pressure Ulcer Prevention and Management\n\n \xef\x82\xb7\t CLC Resident Independence and Dignity\n\n \xef\x82\xb7\t Construction Safety\n\nWe have listed the general information reviewed for each of these activities. Some of\nthe items listed may not have been applicable to this facility because of a difference in\nsize, function, or frequency of occurrence.\n\n\n\n\nVA OIG Office of Healthcare Inspections 1\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nThe review covered facility operations for FY 2012, FY 2013, and FY 2014 through\nMarch 27, 2014, and was done in accordance with OIG standard operating procedures\nfor CAP reviews. We also asked the facility to provide the status on the\nrecommendations we made in our previous CAP report (Combined Assessment\nProgram Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina,\nReport No. 08-03078-44, December 9, 2009). We made a repeat recommendation\nrelated to MH EOC training.\n\nDuring this review, we presented crime awareness briefings for 93 employees. These\nbriefings covered procedures for reporting suspected criminal activity to the OIG and\nincluded case-specific examples illustrating procurement fraud, conflicts of interest, and\nbribery.\n\nAdditionally, we surveyed employees regarding patient safety and quality of care at the\nfacility. An electronic survey was made available to all facility employees, and\n416 responded. We shared summarized results with facility managers.\n\nIn this report, we make recommendations for improvement. Recommendations pertain\nto issues that are significant enough to be monitored by the OIG until corrective actions\nare implemented.\n\n Reported Accomplishments\n\nRobotic Surgery System\nIn November 2012, the facility became 1 of 3 VISN 6 facilities approved to perform\nrobotic surgery. The robotic surgery system provides surgeons the ability to perform\ncomplex procedures through small surgical incisions and supports collaboration\nbetween surgeons. The goal of the robotic surgery system is to train surgeons to\nperform procedures safely and effectively and to reduce complications and improve\nsurgical outcomes. Since the March 2013 initiation, the facility has increased the\nnumber of robotic radical prostatectomies,a while reducing hospital length of stay and\npost-operative complications by 50 percent and patients\xe2\x80\x99 estimated blood loss by\n80 percent.\n\nHospice and CLC Renovations\nIn November 2010, the facility initiated a 3-phase minor capital improvement project to\ncreate a Long-Term Care Center of Excellence. Phase 1 has been completed and\ninvolved renovating the hospice unit to include 12 beds with private rooms and\nbathrooms; a 6 room/12 bed temporary lodging option for veterans; and a Main Street\nconcept in the atrium of the CLC with various shops, activities, a 24-hour theatre, a town\nhall, and a barbershop. These improvements create a sense of comfort and familiarity\nand a community environment within the CLC.\n\na\n A radical prostatectomy is an operation to remove the prostate gland and some of the tissue around it. It is done to\nremove prostate cancer.\n\n\nVA OIG Office of Healthcare Inspections 2\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n Results and Recommendations \n\nQM\nThe purpose of this review was to determine whether facility senior managers actively supported\nand appropriately responded to QM efforts and whether the facility met selected requirements\nwithin its QM program.1\n\nWe conversed with senior managers and key QM employees, and we evaluated meeting\nminutes, EHRs, and other relevant documents. The table below shows the areas reviewed for\nthis topic. The areas marked as NM did not meet applicable requirements and needed\nimprovement. Any items that did not apply to this facility are marked NA.\n\nNM Areas Reviewed Findings\n There was a senior-level committee/group\n responsible for QM/performance improvement\n that met regularly.\n \xef\x82\xb7 There was evidence that outlier data was\n acted upon.\n \xef\x82\xb7 There was evidence that QM, patient\n safety, and systems redesign were\n integrated.\n The protected peer review process met\n selected requirements:\n \xef\x82\xb7 The PRC was chaired by the Chief of Staff\n and included membership by applicable\n service chiefs.\n \xef\x82\xb7 Actions from individual peer reviews were\n completed and reported to the PRC.\n \xef\x82\xb7 The PRC submitted quarterly summary\n reports to the MEC.\n \xef\x82\xb7 Unusual findings or patterns were\n discussed at the MEC.\n Focused Professional Practice Evaluations for\n newly hired licensed independent practitioners\n were initiated and completed, and results\n were reported to the MEC.\n NA Specific telemedicine services met selected\n requirements:\n \xef\x82\xb7 Services were properly approved.\n \xef\x82\xb7 Services were provided and/or received by\n appropriately privileged staff.\n \xef\x82\xb7 Professional practice evaluation information\n was available for review.\n\n\n\n\nVA OIG Office of Healthcare Inspections 3\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNM Areas Reviewed (continued) Findings\n Observation bed use met selected\n requirements:\n \xef\x82\xb7 Local policy included necessary elements.\n \xef\x82\xb7 Data regarding appropriateness of\n observation bed usage was gathered.\n \xef\x82\xb7 If conversions to acute admissions were\n consistently 30 percent or more,\n observation criteria and utilization were\n reassessed timely.\n Staff performed continuing stay reviews on at\n least 75 percent of patients in acute beds.\n The process to review resuscitation events\n met selected requirements:\n \xef\x82\xb7 An interdisciplinary committee was\n responsible for reviewing episodes of care\n where resuscitation was attempted.\n \xef\x82\xb7 Resuscitation event reviews included\n screening for clinical issues prior to events\n that may have contributed to the\n occurrence of the code.\n \xef\x82\xb7 Data were collected that measured\n performance in responding to events.\n X The surgical review process met selected \xef\x82\xb7 The Surgical Work Group only met 5 times\n requirements: over the past 7 months.\n \xef\x82\xb7 An interdisciplinary committee with\n Several surgical deaths occurred from July\n appropriate leadership and clinical\n through December 2013:\n membership met monthly to review surgical\n \xef\x82\xb7 There was no evidence that some of the\n processes and outcomes.\n deaths were reviewed.\n \xef\x82\xb7 All surgical deaths were reviewed.\n \xef\x82\xb7 Additional data elements were routinely\n reviewed.\n Critical incidents reporting processes were\n appropriate.\n X The process to review the quality of entries in Twelve months of EHR Committee meeting\n the EHR met selected requirements: minutes reviewed:\n \xef\x82\xb7 A committee was responsible to review \xef\x82\xb7 There was no evidence that the quality of\n EHR quality. entries in the EHR was reviewed.\n \xef\x82\xb7 Data were collected and analyzed at least\n quarterly.\n \xef\x82\xb7 Reviews included data from most services\n and program areas.\n The policy for scanning non-VA care\n documents met selected requirements.\n\n\n\n\nVA OIG Office of Healthcare Inspections 4\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNM Areas Reviewed (continued) Findings\n X The process to review blood/transfusions Five sets of Blood Usage Review Committee\n usage met selected requirements: meeting minutes reviewed:\n \xef\x82\xb7 A committee with appropriate clinical \xef\x82\xb7 Clinical representatives from Surgery and\n membership met at least quarterly to review Anesthesia Services only attended three\n blood/transfusions usage. meetings, and a clinical representative from\n \xef\x82\xb7 Additional data elements were routinely Medicine Service only attended one meeting.\n reviewed.\n Overall, if significant issues were identified,\n actions were taken and evaluated for\n effectiveness.\n Overall, senior managers were involved in\n performance improvement over the past\n 12 months.\n Overall, the facility had a comprehensive,\n effective QM/performance improvement\n program over the past 12 months.\n X The facility met any additional elements In response to a hotline allegation that the\n required by VHA or local policy. facility was expediting delinquent OPPEs prior to\n our visit, we reviewed the OPPE process. Local\n policy requires OPPEs to be completed and\n reported to the Professional Standards Board\n every 6 months. We found that the tracking\n process was flawed and that OPPEs were not\n completed or reported timely. Between\n February 4 and March 26, 2014, the facility\n eliminated the backlog of 131 OPPEs and\n provided a plan to ensure better tracking and\n timely reporting.\n\nRecommendations\n\n1. We recommended that the Surgical Work Group meet monthly.\n\n2. We recommended that processes be strengthened to ensure that all surgical deaths are\nreviewed.\n\n3. We recommended that processes be strengthened to ensure that the quality of entries in\nthe EHR is reviewed at least quarterly.\n\n4. We recommended that processes be strengthened to ensure that the Blood Usage Review\nCommittee members from Surgery, Medicine, and Anesthesia Services consistently attend\nmeetings.\n\n5. We recommended that the facility implement their plan to track OPPEs and present them to\nthe Professional Standards Board within the timeframe required by local policy and that\ncompliance be monitored.\n\n\n\n\nVA OIG Office of Healthcare Inspections 5\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nEOC\nThe purpose of this review was to determine whether the facility maintained a clean and safe\nhealth care environment in accordance with applicable requirements and whether selected\nrequirements in radiology and acute MH were met.2\n\nWe inspected medical/surgical unit 2-3, intensive care unit 2-3, CLC unit 42-2C, the emergency\ndepartment, the primary care clinic Green Team, the podiatry clinic, x-ray and fluoroscopy, and\nacute MH units 4-3A and 4-3B. Additionally, we reviewed relevant documents, conversed with\nkey employees and managers, and reviewed 29 employee training records (10 radiology\nemployees, 9 acute MH unit employees, 5 MSIT members, and 5 occasional acute MH unit\nemployees). The table below shows the areas reviewed for this topic. The areas marked as\nNM did not meet applicable requirements and needed improvement. Any items that did not\napply to this facility are marked NA.\n\nNM Areas Reviewed for General EOC Findings\n EOC Committee minutes reflected sufficient\n detail regarding identified deficiencies,\n corrective actions taken, and tracking of\n corrective actions to closure.\n An infection prevention risk assessment was\n conducted, and actions were implemented to\n address high-risk areas.\n Infection Prevention/Control Committee\n minutes documented discussion of identified\n problem areas and follow-up on implemented\n actions and included analysis of surveillance\n activities and data.\n Fire safety requirements were met. \xc2\xa0\n Environmental safety requirements were met.\n Infection prevention requirements were met.\n Medication safety and security requirements\n were met.\n Auditory privacy requirements were met.\n The facility complied with any additional\n elements required by VHA, local policy, or\n other regulatory standards.\n Areas Reviewed for Radiology\n The facility had a Radiation Safety Committee, \xc2\xa0\n the committee met at least every 6 months\n and established a quorum for meetings, and\n the Radiation Safety Officer attended\n meetings.\n Radiation Safety Committee meeting minutes\n reflected discussion of any problematic areas,\n corrective actions taken, and tracking of\n corrective actions to closure.\n\n\n\n\nVA OIG Office of Healthcare Inspections 6\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNM Areas Reviewed for Radiology (continued) Findings\n Facility policy addressed frequencies of\n equipment inspection, testing, and\n maintenance.\n The facility had a policy for the safe use of\n fluoroscopic equipment.\n The facility Director appointed a Radiation\n Safety Officer to direct the radiation safety\n program.\n X-ray and fluoroscopy equipment items were\n tested by a qualified medical physicist before\n placed in service and annually thereafter, and\n quality control was conducted on fluoroscopy\n equipment in accordance with facility\n policy/procedure.\n Designated employees received initial\n radiation safety training and training thereafter\n with the frequency required by local policy,\n and radiation exposure monitoring was\n completed for employees within the past year.\n Environmental safety requirements in x-ray\n and fluoroscopy were met.\n Infection prevention requirements in x-ray and\n fluoroscopy were met.\n Medication safety and security requirements\n in x-ray and fluoroscopy were met.\n Sensitive patient information in x-ray and\n fluoroscopy was protected.\n The facility complied with any additional\n elements required by VHA, local policy, or\n other regulatory standards.\n Areas Reviewed for Acute MH\n MH EOC inspections were conducted every\n 6 months.\n Corrective actions were taken for \xc2\xa0\n environmental hazards identified during\n inspections, and actions were tracked to\n closure.\n X MH unit staff, MSIT members, and occasional \xef\x82\xb7 One of the MSIT members and all five of the\n unit workers received training on how to occasional locked MH unit workers had not\n identify and correct environmental hazards, completed training on how to identify and\n content and proper use of the MH EOC correct environmental hazards, proper use of\n Checklist, and VA\xe2\x80\x99s National Center for the MH EOC Checklist, and VA\xe2\x80\x99s National\n Patient Safety study of suicide on psychiatric Center for Patient Safety study of suicide on\n units. psychiatric units. This was a repeat finding\n from the previous CAP review.\xc2\xa0\n\n\n\n\nVA OIG Office of Healthcare Inspections 7\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNM Areas Reviewed for Acute MH (continued) Findings\n X The locked MH units were in compliance with \xef\x82\xb7 Although panic alarm testing was conducted,\n MH EOC Checklist safety requirements or an VA Police response time was not\n abatement plan was in place. documented for the past 2 months.\n \xef\x82\xb7 Seclusion room floors did not have a\n cushioned surface.\n The facility complied with any additional \xc2\xa0\n elements required by VHA, local policy, or\n other regulatory standards.\n\nRecommendations\n\n6. We recommended that processes be strengthened to ensure that all MSIT members and\noccasional locked MH unit workers receive training on how to identify and correct environmental\nhazards, proper use of the MH EOC Checklist, and VA\xe2\x80\x99s National Center for Patient Safety\nstudy of suicide on psychiatric units and that compliance be monitored.\n\n7. We recommended that processes be strengthened to ensure that locked MH unit panic\nalarm testing documentation includes VA Police response time.\n\n8. We recommended that the locked MH units\xe2\x80\x99 seclusion room floors have a cushioned\nsurface.\n\n\n\n\nVA OIG Office of Healthcare Inspections 8\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nMedication Management\nThe purpose of this review was to determine whether the appropriate clinical oversight and\neducation were provided to patients discharged with orders for fluoroquinolone oral antibiotics.3\n\nWe reviewed relevant documents and conversed with key managers and employees.\nAdditionally, we reviewed the EHRs of 35 randomly selected inpatients discharged on 1 of\n3 selected oral antibiotics. The table below shows the areas reviewed for this topic. Any items\nthat did not apply to this facility are marked NA. The facility generally met requirements. We\nmade no recommendations.\n\nNM Areas Reviewed Findings\n Clinicians conducted inpatient learning\n assessments within 24 hours of admission or\n earlier if required by local policy.\n If learning barriers were identified as part of\n the learning assessment, medication\n counseling was adjusted to accommodate the\n barrier(s).\n Patient renal function was considered in\n fluoroquinolone dosage and frequency.\n Providers completed discharge progress\n notes or discharge instructions, written\n instructions were provided to\n patients/caregivers, and EHR documentation\n reflected that the instructions were\n understood.\n Patients/caregivers were provided a written\n medication list at discharge, and the\n information was consistent with the dosage\n and frequency ordered.\n Patients/caregivers were offered medication\n counseling, and this was documented in\n patient EHRs.\n The facility established a process for\n patients/caregivers regarding whom to notify\n in the event of an adverse medication event.\n The facility complied with any additional\n elements required by VHA or local policy.\n\n\n\n\nVA OIG Office of Healthcare Inspections 9\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nCoordination of Care\nThe purpose of this review was to evaluate discharge planning for patients with selected\naftercare needs.4\n\nWe reviewed relevant documents, and we conversed with key employees. Additionally, we\nreviewed the EHRs of 22 patients with specific diagnoses who were discharged from\nJuly 1, 2012, through June 30, 2013. The table below shows the areas reviewed for this topic.\nAny items that did not apply to this facility are marked NA. The facility generally met\nrequirements. We made no recommendations.\n\nNM Areas Reviewed Findings\n Patients\xe2\x80\x99 post-discharge needs were\n identified, and discharge planning addressed\n the identified needs.\n Clinicians provided discharge instructions to\n patients and/or caregivers and validated their\n understanding.\n Patients received the ordered aftercare\n services and/or items within the\n ordered/expected timeframe.\n Patients\xe2\x80\x99 and/or caregivers\xe2\x80\x99 knowledge and\n learning abilities were assessed during the\n inpatient stay.\n The facility complied with any additional\n elements required by VHA or local policy.\n\n\n\n\nVA OIG Office of Healthcare Inspections 10\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNurse Staffing\nThe purpose of this review was to determine whether the facility implemented the staffing\nmethodology for nursing personnel and completed annual reassessments and to evaluate nurse\nstaffing on three inpatient units (acute medical/surgical, long-term care, and MH).5\n\nWe reviewed facility and unit-based expert panel documents and 24 training files, and we\nconversed with key employees. Additionally, we reviewed the actual nursing hours per patient\nday for 3 randomly selected units\xe2\x80\x94acute medical/surgical unit 2-3, CLC unit 42-C, and MH unit\n4-3A\xe2\x80\x94for 50 randomly selected days between October 1, 2012, and September 30, 2013. The\ntable below shows the areas reviewed for this topic. The area marked as NM did not meet\napplicable requirements and needed improvement. Any items that did not apply to this facility\nare marked NA.\n\nNM Areas Reviewed Findings\n X The facility either implemented or reassessed \xef\x82\xb7 Initial implementation was not completed until\n a nurse staffing methodology within the October 25, 2013.\n expected timeframes.\n The facility expert panel followed the required\n processes and included the required\n members.\n The unit-based expert panels followed the\n required processes and included the required\n members.\n Members of the expert panels completed the\n required training.\n The actual nursing hours per patient day met\n or exceeded the target nursing hours per\n patient day.\n The facility complied with any additional\n elements required by VHA or local policy.\n\nRecommendation\n\n9. We recommended that nursing managers monitor the staffing methodology implemented in\nOctober 2013.\n\n\n\n\nVA OIG Office of Healthcare Inspections 11\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nPressure Ulcer Prevention and Management\nThe purpose of this review was to determine whether acute care clinicians provided\ncomprehensive pressure ulcer prevention and management.6\n\nWe reviewed relevant documents, 21 EHRs of patients with pressure ulcers (8 patients with\nhospital-acquired pressure ulcers, 10 patients with community-acquired pressure ulcers, and\n3 patients with pressure ulcers at the time of our onsite visit), and 10 employee training records.\nAdditionally, we inspected three patient rooms. The table below shows the areas reviewed for\nthis topic. The areas marked as NM did not meet applicable requirements and needed\nimprovement. Any items that did not apply to this facility are marked NA.\n\nNM Areas Reviewed Findings\n The facility had a pressure ulcer prevention\n policy, and it addressed prevention for all\n inpatient areas and for outpatient care.\n The facility had an interprofessional pressure\n ulcer committee, and the membership\n included a certified wound care specialist.\n Pressure ulcer data was analyzed and\n reported to facility executive leadership.\n Complete skin assessments were performed\n within 24 hours of acute care admissions.\n Skin inspections and risk scales were\n performed upon transfer, change in condition,\n and discharge.\n X Staff were generally consistent in \xef\x82\xb7 In 6 of the 21 EHRs, documentation of\n documenting location, stage, risk scale score, location, stage, risk scale score, and/or date\n and date acquired. acquired varied.\n Required activities were performed for\n patients determined to be at risk for pressure\n ulcers and for patients with pressure ulcers.\n Required activities were performed for\n patients determined to not be at risk for\n pressure ulcers.\n For patients at risk for and with pressure\n ulcers, interprofessional treatment plans were\n developed, interventions were recommended,\n and EHR documentation reflected that\n interventions were provided.\n If the patient\xe2\x80\x99s pressure ulcer was not healed\n at discharge, a wound care follow-up plan was\n documented, and the patient was provided\n appropriate dressing supplies.\n\n\n\n\nVA OIG Office of Healthcare Inspections 12\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNM Areas Reviewed (continued) Findings\n X The facility defined requirements for patient Facility pressure ulcer patient and caregiver\n and caregiver pressure ulcer education, and education requirements reviewed:\n education on pressure ulcer prevention and \xef\x82\xb7 For 5 of the applicable 14 patients at risk\n development was provided to those at risk for for/with a pressure ulcer, EHRs did not\n and with pressure ulcers and/or their contain evidence that education was\n caregivers. provided.\n The facility defined requirements for staff\n pressure ulcer education, and acute care staff\n received training on how to administer the\n pressure ulcer risk scale, conduct the\n complete skin assessment, and accurately\n document findings.\n The facility complied with selected fire and\n environmental safety, infection prevention,\n and medication safety and security\n requirements in pressure ulcer patient rooms.\n The facility complied with any additional\n elements required by VHA or local policy.\n\nRecommendations\n\n10. We recommended that processes be strengthened to ensure that acute care staff\naccurately document location, stage, risk scale score, and date pressure ulcer acquired for all\npatients with pressure ulcers and that compliance be monitored.\n\n11. We recommended that processes be strengthened to ensure that acute care staff provide\nand document pressure ulcer education for patients at risk for and with pressure ulcers and/or\ntheir caregivers and that compliance be monitored.\n\n\n\n\nVA OIG Office of Healthcare Inspections 13\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nCLC Resident Independence and Dignity\nThe purpose of this review was to determine whether VHA facilities provided CLC restorative\nnursing services and complied with selected nutritional management and dining service\nrequirements to assist CLC residents in maintaining their optimal level of functioning,\nindependence, and dignity.7\n\nWe reviewed 20 EHRs of residents (10 residents receiving restorative nursing services and\n10 residents not receiving restorative nursing services but candidates for services). We also\nobserved 8 residents during 2 meal periods, reviewed 10 employee training/competency records\nand other relevant documents, and conversed with key employees. The table below shows the\nareas reviewed for this topic. The area marked as NM did not meet applicable requirements\nand needed improvement. Any items that did not apply to this facility are marked NA.\n\nNM Areas Reviewed Findings\n The facility offered restorative nursing\n services.\n Facility staff completed and documented\n restorative nursing services, including active\n and passive range of motion, bed mobility,\n transfer, and walking activities, according to\n clinician orders and residents\xe2\x80\x99 care plans.\n Resident progress towards restorative nursing\n goals was documented, and interventions\n were modified as needed to promote the\n resident\xe2\x80\x99s accomplishment of goals.\n When restorative nursing services were care\n planned but were not provided or were\n discontinued, reasons were documented in\n the EHR.\n If residents were discharged from physical\n therapy, occupational therapy, or\n kinesiotherapy, there was hand-off\n communication between Physical Medicine\n and Rehabilitation Service and the CLC to\n ensure that restorative nursing services\n occurred.\n Training and competency assessment were\n completed for staff who performed restorative\n nursing services.\n The facility complied with any additional\n elements required by VHA or local policy.\n Areas Reviewed for Assistive Eating\n Devices and Dining Service\n X Care planned/ordered assistive eating devices \xef\x82\xb7 Two of 15 assistive eating devices care\n were provided to residents at meal times. planned/ordered were not provided to\n residents at meal time.\n\n\n\n\nVA OIG Office of Healthcare Inspections 14\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n Areas Reviewed for Assistive Eating\n Devices and Dining Service (continued)\n Required activities were performed during\n resident meal periods.\n The facility complied with any additional\n elements required by VHA or local policy.\n\nRecommendation\n\n12. We recommended that processes be strengthened to ensure that all care planned/ordered\nassistive eating devices are provided to residents for use during meals.\n\n\n\n\nVA OIG Office of Healthcare Inspections 15\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nConstruction Safety\nThe purpose of this review was to determine whether the facility maintained infection control and\nsafety precautions during construction and renovation activities in accordance with applicable\nstandards.8\n\nWe inspected the B2 emergency department holding room and bathroom renovation.\nAdditionally, we reviewed relevant documents and 10 employee training records, and we\nconversed with key employees and managers. The table below shows the areas reviewed for\nthis topic. The areas marked as NM did not meet applicable requirements and needed\nimprovement. Any items that did not apply to this facility are marked NA.\n\nNM Areas Reviewed Findings\n There was a multidisciplinary committee to\n oversee infection control and safety\n precautions during construction and\n renovation activities and a policy outlining the\n responsibilities of the committee, and the\n committee included all required members.\n Infection control, preconstruction, interim life\n safety, and contractor tuberculosis risk\n assessments were conducted prior to project\n initiation.\n NA There was documentation of results of\n contractor tuberculosis skin testing and of\n follow-up on any positive results.\n There was a policy addressing Interim Life\n Safety Measures, and required Interim Life\n Safety Measures were documented.\n X Site inspections were conducted by the Site inspection documentation for 2 quarters\n required multidisciplinary team members at reviewed:\n the specified frequency and included all \xef\x82\xb7 We did not find documented evidence of the\n required elements. time of the inspection and the time when\n corrective actions occurred.\n X Infection Control Committee minutes Infection Control Committee minutes for past\n documented infection surveillance activities 2 quarters reviewed:\n associated with the project(s) and any \xef\x82\xb7 There was inconsistent documentation of\n interventions. infection surveillance activities related to the\n project.\n Construction Safety Committee minutes\n documented any unsafe conditions found\n during inspections and any follow-up actions\n and tracked actions to completion.\n Contractors and designated employees\n received required training.\n Dust control requirements were met.\n Fire and life safety requirements were met.\n Hazardous chemicals requirements were met.\n Storage and security requirements were met.\n\n\n\nVA OIG Office of Healthcare Inspections 16\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nNM Areas Reviewed (continued) Findings\n The facility complied with any additional\n elements required by VHA or local policy or\n other regulatory standards.\n\nRecommendations\n\n13. We recommended that processes be strengthened to ensure that inspection documentation\nincludes the time of the inspection and the time when corrective actions occurred.\n14. We recommended that processes be strengthened to ensure that infection surveillance\nactivities related to construction projects are consistently conducted and documented in\nInfection Control Committee minutes.\n\n\n\n\nVA OIG Office of Healthcare Inspections 17\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix A\n\n\n Facility Profile (Salisbury/659) FY 2014 through March 2014b\nType of Organization Tertiary\nComplexity Level 1c-High complexity\nAffiliated/Non-Affiliated Affiliated\nTotal Medical Care Budget in Millions $372.9\nNumber of:\n \xef\x82\xb7 Unique Patients 68,678\n \xef\x82\xb7 Outpatient Visits 405,584\n \xef\x82\xb7 Unique Employeesc 2,002\nType and Number of Operating Beds (February 2014):\n \xef\x82\xb7 Hospital 107\n \xef\x82\xb7 CLC 270\n \xef\x82\xb7 MH 35\nAverage Daily Census:\n \xef\x82\xb7 Hospital 75\n \xef\x82\xb7 CLC 105\n \xef\x82\xb7 MH 26\nNumber of Community Based Outpatient Clinics 3\nLocation(s)/Station Number(s) Winston-Salem/659BY\n Charlotte/659GA\n Hickory/659GB\nVISN Number 6\n\n\n\n\nb\n All data is for FY 2014 through March 2014 except where noted. \n\nc\n Unique employees involved in direct medical care (cost center 8200) from most recent pay period. \n\n\n\nVA OIG Office of Healthcare Inspections 18\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix B\n\n Strategic Analytics for Improvement and Learning (SAIL)d\n\n\n\n\nd\n Metric definitions follow the graphs.\n\n\nVA OIG Office of Healthcare Inspections 19\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n Scatter Chart \n\n\n\n\n\nVA OIG Office of Healthcare Inspections 20\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n Metric Definitions\n Measure Definition Desired direction\n ACSC Hospitalization Ambulatory care sensitive condition hospitalizations (observed to expected ratio) A lower value is better than a higher value\n Adjusted LOS Acute care risk adjusted length of stay A lower value is better than a higher value\n Call Center Responsiveness Average speed of call center responded to calls in seconds A lower value is better than a higher value\n Call Responsiveness Call center speed in picking up calls and telephone abandonment rate A lower value is better than a higher value\n Complications Acute care risk adjusted complication ratio A lower value is better than a higher value\n Efficiency Overall efficiency measured as 1 divided by SFA (Stochastic Frontier Analysis) A higher value is better than a lower value\n Employee Satisfaction Overall satisfaction with job A higher value is better than a lower value\n HC Assoc Infections Health care associated infections A lower value is better than a higher value\n HEDIS Outpatient performance measure (HEDIS) A higher value is better than a lower value\n MH Status MH status (outpatient only, the Veterans RAND 12 Item Health Survey) A higher value is better than a lower value\n MH Wait Time MH wait time for new and established patients (top 50 clinics) A higher value is better than a lower value\n Oryx Inpatient performance measure (ORYX) A higher value is better than a lower value\n Physical Health Status Physical health status (outpatient only, the Veterans RAND 12 item Health Survey) A higher value is better than a lower value\n Primary Care Wait Time Primary care wait time for new and established patients (top 50 clinics) A higher value is better than a lower value\n PSI Patient safety indicator A lower value is better than a higher value\n Pt Satisfaction Overall rating of hospital stay (inpatient only) A higher value is better than a lower value\n RN Turnover Registered nurse turnover rate A lower value is better than a higher value\n RSMR-AMI 30-day risk standardized mortality rate for acute myocardial infarction A lower value is better than a higher value\n RSMR-CHF 30-day risk standardized mortality rate for congestive heart failure A lower value is better than a higher value\n RSMR-Pneumonia 30-day risk standardized mortality rate for pneumonia A lower value is better than a higher value\n RSRR-AMI 30-day risk standardized readmission rate for acute myocardial infarction A lower value is better than a higher value\n RSRR-CHF 30-day risk standardized readmission rate for congestive heart failure A lower value is better than a higher value\n RSRR-Pneumonia 30-day risk standardized readmission rate for pneumonia A lower value is better than a higher value\n SMR Acute care in-hospital standardized mortality ratio A lower value is better than a higher value\n SMR30 Acute care 30-day standardized mortality ratio A lower value is better than a higher value\n Specialty Care Wait Time Specialty care wait time for new and established patients (top 50 clinics) A higher value is better than a lower value\n\n\n\n\nVA OIG Office of Healthcare Inspections 21\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix C\n VISN Director Comments\n\n\n\n Department of\n Veterans Affairs Memorandum\n\n\n Date: April 29, 2014\n\n From: Director, VA Mid-Atlantic Health Care Network (10N6)\n\n Subject: \t CAP Review of the W.G. (Bill) Hefner VA Medical Center,\n Salisbury, NC\n\n To: Director, Atlanta Office of Healthcare Inspections (54AT)\n\n Director, Management Review Service (VHA 10AR MRS\n OIG CAP CBOC)\n\n 1. The attached subject report is forwarded for your review and further\n action. I reviewed the response of the W. G. (Bill) Hefner VA Medical\n Center (VAMC), Salisbury, NC, and concur with the facility\xe2\x80\x99s\n recommendations.\n\n 2. If you have further questions, please contact Lisa Shear, VISN 6 QMO,\n at (919) 956-5541.\n\n\n (original signed by:)\n DANIEL F. HOFFMANN, FACHE\n\n\n\n\nVA OIG Office of Healthcare Inspections 22\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix D\n Facility Director Comments\n\n\n\n Department of\n Veterans Affairs Memorandum\n\n\n Date: April 28, 2014\n\n From: Director, W.G. (Bill) Hefner VA Medical Center (659/00)\n\n Subject: CAP Review of the W.G. (Bill) Hefner VA Medical Center,\n Salisbury, NC\n\n To: Director, VA Mid-Atlantic Health Care Network (10N6)\n\n 1. I have reviewed the draft report of the Office of Inspector General and I\n concur with the recommendations.\n 2. I have included my response in the attached Director\xe2\x80\x99s Comments.\n 3. Please contact me if you have any questions or comments.\n\n\n (original signed by:)\n KAYE GREEN, FACHE\n\n\n\n\nVA OIG Office of Healthcare Inspections 23\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n Comments to OIG\xe2\x80\x99s Report\n\nThe following Director\xe2\x80\x99s comments are submitted in response to the recommendations\nin the OIG report:\n\nOIG Recommendations\n\nRecommendation 1. We recommended that the Surgical Work Group meet monthly.\n\nConcur\n\nTarget date for completion: Completed\n\nFacility response: The surgical work group has been meeting monthly as required since\nSeptember 2013. The minutes will be reported monthly to the CEB until closure by the\nOIG and then revert to a quarterly frequency.\n\nRecommendation 2. We recommended that processes be strengthened to ensure that\nall surgical deaths are reviewed.\n\nConcur\n\nTarget date for completion: Completed April 22, 2014\n\nFacility response: The 5 cases not included in the mortality and morbidity conferences\nwere reviewed and included in the April 22, 2014 Surgical Work Group minutes. The\nVASQIP nurse will monitor monthly surgical work group minutes to ensure that there is\ndocumentation that all surgical deaths were assessed in a mortality and morbidity\nconference. This monitor will be reported to CEB monthly for oversight.\n\nRecommendation 3. We recommended that processes be strengthened to ensure that\nthe quality of entries in the EHR is reviewed at least quarterly.\n\nConcur\n\nTarget date for completion: Completed\n\nFacility response: Medical Records Committee has developed a reporting matrix for\nreview of the quality of entries in the EHR. This matrix includes all services with staff\nwho document in the EHR. Reviews are scheduled for each quarter to ensure data is\ncollected and analyzed at least quarterly. Compliance will be monitored monthly and\nreported to CEB until closure by OIG, and then it will revert to a quarterly reporting\nfrequency.\n\n\n\n\nVA OIG Office of Healthcare Inspections 24\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nRecommendation 4. We recommended that processes be strengthened to ensure that\nthe Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia\nServices consistently attend meetings.\n\nConcur\n\nTarget date for completion: Completed April 9, 2014\n\nFacility response: Members were notified of the attendance requirement.\nRepresentatives from all three departments attended the Blood Utilization Review\nmeeting on April 9, 2014. Committee attendance will be monitored monthly until OIG\nclosure to ensure anesthesia, surgery and medicine representatives are present at the\nmeeting. Monthly reports will be provided to CEB for ongoing oversight.\n\nRecommendation 5. We recommended that the facility implement their plan to track\nOPPEs and present them to the Professional Standards Board within the timeframe\nrequired by local policy and that compliance be monitored.\n\nConcur\n\nTarget date for completion: Completed March 26, 2014\n\nFacility response: A process using electronic software, Privplus, has been implemented\nto track OPPEs and send notices prior to their due date to ensure OPPEs are\ncompleted timely. There were no overdue OPPEs as of March 26, 2014. Compliance\nwill be monitored and reported monthly to the CEB for ongoing oversight.\n\nRecommendation 6. We recommended that processes be strengthened to ensure that\nall MSIT members and occasional locked MH unit workers receive training on how to\nidentify and correct environmental hazards, proper use of the MH EOC Checklist, and\nVA\xe2\x80\x99s National Center for Patient Safety study of suicide on psychiatric units and that\ncompliance be monitored.\n\nConcur\n\nTarget date for completion: June 15, 2014\n\nFacility response: All MSIT members and occasional locked MH unit employees will\ncomplete mandatory training on how to identify and correct environmental hazards,\nproper use of the MH EOC Checklist, and VA\xe2\x80\x99s National Center for Patient Safety study\nof suicide on psychiatric units. Training must be completed by 6/15/14. The education\ndepartment will monitor compliance with training requirements. Compliance will be\nreported to CEB and ELB for ongoing oversight.\n\n\n\n\nVA OIG Office of Healthcare Inspections 25\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nRecommendation 7. We recommended that processes be strengthened to ensure that\nlocked MH unit panic alarm testing documentation includes VA Police response time.\n\nConcur\n\nTarget date for completion: May 30, 2014\n\nFacility response: The police dispatchers will begin tracking response times to panic\nalarms in the locked mental health units beginning May 1, 2014. This will be reported\nmonthly to the Environment of Care Committee beginning June 2014. In addition, two\nresponse drills are conducted annually and the response times are tracked. These will\nbe reported to the Environment of Care Committee.\n\nRecommendation 8. We recommended that the locked MH units\xe2\x80\x99 seclusion rooms\nhave a cushioned surface.\n\nConcur\n\nTarget date for completion: June 30, 2014\n\nFacility response: The locked mental health units are scheduled to move to a new\nbuilding on June 30, 2014. The seclusion rooms in the new building have a cushioned\nsurface. In the interim, padded mats will be placed in the current seclusion rooms and\npatients continuously observed.\n\nRecommendation 9. We recommended that nursing managers monitor the staffing\nmethodology implemented in October 2013.\n\nConcur\n\nTarget date for completion: Completed and Ongoing\n\nFacility response: Staffing methodology was fully implemented in October 2013.\nStaffing methodology will be monitored and reported to the Nurse Executive Council\nmonthly until OIG closure and then will continue to be monitored as per VHA\nDirective 2010-034.\n\nRecommendation 10. We recommended that processes be strengthened to ensure\nthat acute care staff accurately document location, stage, risk scale score, and date\npressure ulcer acquired for all patients with pressure ulcers and that compliance be\nmonitored.\n\nConcur\n\nTarget date for completion: May 30, 2014\n\nFacility response: The Acute Care Wound Care Specialist will train pressure ulcer\nprevention champions on each shift by April 30, 2014. These Pressure Ulcer\n\n\n\nVA OIG Office of Healthcare Inspections 26\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nChampions will train front line staff by May 30, 2014, to ensure accurate documentation\nof location, stage, risk scale score, and date pressure ulcer acquired. The Acute Care\nWound Care Specialist will monitor wound care documentation to ensure 90 percent\ncompliance with requirements and will report monthly to Nurse Executive Committee for\noversight.\n\nRecommendation 11. We recommended that processes be strengthened to ensure\nthat acute care staff provide and document pressure ulcer education for patients at risk\nfor and with pressure ulcers and/or their caregivers and that compliance be monitored.\n\nConcur\n\nTarget date for completion: Completed April 16, 2014\n\nFacility response: Acute Care nursing staff have been reeducated that pressure ulcer\nprevention education must be given to patients and/or their caregivers. Staff was also\neducated that the Admission Assessment template in CPRS was revised so to ensure a\nconsistent method for documenting that this education occurred. The revised template\nwas implemented in CPRS on April 16, 2014. The acute care wound care specialist will\nmonitor wound care documentation to ensure it meets 90 percent compliance with\npatient education documentation requirements. This will be reported monthly to Nurse\nExecutive Committee for oversight.\n\nRecommendation 12. We recommended that processes be strengthened to ensure\nthat all care planned/ordered assistive eating devices are provided to residents for use\nduring meals.\n\nConcur\n\nTarget date for completion: May 2, 2014\n\nFacility response: Each tray has a ticket on it with the Resident's Name, Room, Diet,\nand menu. This ticket has been revised so the need for any adaptive equipment is\nclearly visible. Food and Nutrition Staff were educated at the April monthly meeting of\nthis change and the need to double check each tray to ensure the proper adaptive\nequipment is present. The Dietary supervisor will complete at least 30 observations per\nmonth to ensure all patients receive ordered adaptive equipment. Compliance will be\nreported monthly to CEB until closure by the OIG with a target of 90 percent.\n\nRecommendation 13. We recommended that processes be strengthened to ensure\nthat inspection documentation includes the time of the inspection and the time when\ncorrective actions occurred.\nConcur\n\nTarget date for completion: Complete April 1, 2014\n\n\n\n\nVA OIG Office of Healthcare Inspections 27\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\nFacility response: Construction Reports format has been revised to include the time of\ninspection and date when the corrective actions occurred. Reports will be monitored\nmonthly by the Chief of Engineering. Compliance will be reported monthly, until OIG\nclosure, to EOC with a target of 90 percent.\n\nRecommendation 14. We recommended that processes be strengthened to ensure\nthat infection surveillance activities related to construction projects are consistently\nconducted and documented in Infection Control Committee minutes.\n\nConcur\n\nTarget date for completion: April 29, 2014\n\nFacility response: A process has been developed to ensure that infection surveillance\nactivities related to construction projects to ensure that they are consistently conducted.\nThese surveillance activities are scheduled in advance and included on a calendar so\nall pertinent parties may participate. The Infection Control Committee has a standing\nagenda item for documentation of surveillance activities of construction projects. The\nInfection Control Committee meeting minutes will be monitored monthly to ensure\ndocumented surveillance of construction projects. Compliance will be reported monthly\nto EOC for ongoing oversight.\n\n\n\n\nVA OIG Office of Healthcare Inspections 28\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix E\n\n\n OIG Contact and Staff Acknowledgments\nContact For more information about this report, please contact the OIG\n at (202) 461-4720.\nOnsite Toni Woodard, BS, Team Leader\nContributors Victoria Coates, LICSW, MBA\n Sheyla Desir, RN, MSN\n Lesa Gann, RN, LCSW\n Joanne Wasko, LCSW\n Bobby Kirby, Special Agent, Office of Investigations\n Scott Bailey, Resident Agent In Charge, Office of Investigations\nOther Elizabeth Bullock\nContributors Shirley Carlile, BA\n Paula Chapman, CTRS\n Lin Clegg, PhD\n Marnette Dhooghe, MS\n Matt Frazier, MPH\n Jeff Joppie, BS\n Victor Rhee, MHS\n Julie Watrous, RN, MS\n Jarvis Yu, MS\n\n\n\n\nVA OIG Office of Healthcare Inspections 29\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix F\n\n\n Report Distribution\nVA Distribution\n\nOffice of the Secretary\nVHA\nAssistant Secretaries\nGeneral Counsel\nDirector, VA Mid-Atlantic Health Care Network (10N6)\nDirector, W.G. (Bill) Hefner VA Medical Center (659/00)\n\nNon-VA Distribution\n\nHouse Committee on Veterans\xe2\x80\x99 Affairs\nHouse Appropriations Subcommittee on Military Construction, Veterans Affairs, and\n Related Agencies\nHouse Committee on Oversight and Government Reform\nSenate Committee on Veterans\xe2\x80\x99 Affairs\nSenate Appropriations Subcommittee on Military Construction, Veterans Affairs, and\n Related Agencies\nSenate Committee on Homeland Security and Governmental Affairs\nNational Veterans Service Organizations\nGovernment Accountability Office\nOffice of Management and Budget\nU.S. Senate: Richard Burr, Kay R. Hagan\nU.S. House of Representatives: Howard Coble, Renee Ellmers, Virginia Foxx,\n Richard Hudson, Patrick T. McHenry, Robert Pittenger\n\n\nThis report is available at www.va.gov/oig.\n\n\n\n\nVA OIG Office of Healthcare Inspections 30\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n Appendix G\n\n Endnotes\n\n1\n References used for this topic included:\n\xef\x82\xb7\t VHA Directive 2009-043, Quality Management System, September 11, 2009.\n\xef\x82\xb7\t VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011.\n\xef\x82\xb7\t VHA Directive 2010-017, Prevention of Retained Surgical Items, April 12, 2010.\n\xef\x82\xb7\t VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.\n\xef\x82\xb7\t VHA Directive 2010-011, Standards for Emergency Departments, Urgent Care Clinics, and Facility Observation\n Beds, March 4, 2010.\n\xef\x82\xb7\t VHA Directive 2009-064, Recording Observation Patients, November 30, 2009.\n\xef\x82\xb7\t VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012.\n\xef\x82\xb7\t VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility\n Cardiopulmonary Resuscitation Committees, October 17, 2008.\n\xef\x82\xb7\t VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012.\n\xef\x82\xb7\t VHA Directive 6300, Records Management, July 10, 2012.\n\xef\x82\xb7\t VHA Directive 2009-005, Transfusion Utilization Committee and Program, February 9, 2009.\n\xef\x82\xb7\t VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, October 6, 2008.\n2\n References used for this topic included:\n\xef\x82\xb7\t VHA Directive 1105.01, Management of Radioactive Materials, October 7, 2009.\n\xef\x82\xb7\t VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011.\n\xef\x82\xb7\t VHA Handbook 1105.04, Fluoroscopy Safety, July 6, 2012.\n\xef\x82\xb7\t VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics,\n September 11, 2008.\n\xef\x82\xb7\t VA Radiology, \xe2\x80\x9cOnline Guide,\xe2\x80\x9d http://vaww1.va.gov/RADIOLOGY/OnLine_Guide.asp, updated\n October 4, 2011.\n\xef\x82\xb7\t VA National Center for Patient Safety, \xe2\x80\x9cPrivacy Curtains and Privacy Curtain Support Structures (e.g., Track and\n Track Supports) in Locked Mental Health Units,\xe2\x80\x9d Patient Safety Alert 07-04, February 16, 2007.\n\xef\x82\xb7\t VA National Center for Patient Safety, \xe2\x80\x9cMulti-Dose Pen Injectors,\xe2\x80\x9d Patient Safety Alert 13-04, January 17, 2013.\n\xef\x82\xb7\t VA National Center for Patient Safety, Mental Health Environment of Care Checklist (MHEOCC),\n April 11, 2013.\n\xef\x82\xb7\t Deputy Under Secretary for Health for Operations and Management, \xe2\x80\x9cMitigation of Items Identified on the\n Environment of Care Checklist,\xe2\x80\x9d November 21, 2008.\n\xef\x82\xb7\t Deputy Under Secretary for Health for Operations and Management, \xe2\x80\x9cChange in Frequency of Review Using the\n Mental Health Environment of Care Checklist,\xe2\x80\x9d April 14, 2010.\n\xef\x82\xb7\t Deputy Under Secretary for Health for Operations and Management, \xe2\x80\x9cGuidance on Locking Patient Rooms on\n Inpatient Mental Health Units Treating Suicidal Patients,\xe2\x80\x9d October 29, 2010.\n\xef\x82\xb7\t U.S. Pharmacopeia <797>, Guidebook to Pharmaceutical Compounding\xe2\x80\x93Sterile Preparations, June 1, 2008.\n\xef\x82\xb7\t 10 CFR 20, Subpart F.\n\xef\x82\xb7\t Various requirements of The Joint Commission, the Occupational Safety and Health Administration, the National\n Fire Protection Association, the Health Insurance Portability and Accountability Act, the American College of\n Radiology Practice Guidelines and Technical Standards, Underwriters Laboratories.\n3\n \xc2\xa0References used for this topic included:\n\xef\x82\xb7\t VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006.\n\xef\x82\xb7\t VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006.\n\xef\x82\xb7\t VHA Directive 2011-012, Medication Reconciliation, March 9, 2011.\n\xef\x82\xb7\t VHA Handbook 1907.01.\n\xef\x82\xb7\t Manufacturer\xe2\x80\x99s instructions for Cipro\xc2\xae and Levaquin\xc2\xae.\n\xef\x82\xb7\t Various requirements of The Joint Commission.\xc2\xa0\n4\n References used for this topic included:\n\xef\x82\xb7\t VHA Handbook 1120.04, Veterans Health Education and Information Core Program Requirements,\n July 29, 2009.\n\xef\x82\xb7\t VHA Handbook 1907.01.\n\xef\x82\xb7\t The Joint Commission, Comprehensive Accreditation Manual for Hospitals, July 2013.\n\n\n\n\nVA OIG Office of Healthcare Inspections 31\n\x0c CAP Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC\n\n\n\n5\n The references used for this topic were:\n\xef\x82\xb7\t VHA Directive 2010-034, Staffing Methodology for VHA Nursing Personnel, July 19, 2010.\n\xef\x82\xb7\t VHA \xe2\x80\x9cStaffing Methodology for Nursing Personnel,\xe2\x80\x9d August 30, 2011.\n6\n References used for this topic included:\n\xef\x82\xb7\t VHA Handbook 1180.02, Prevention of Pressure Ulcers, July 1, 2011 (corrected copy).\n\xef\x82\xb7\t Various requirements of The Joint Commission.\n\xef\x82\xb7\t Agency for Healthcare Research and Quality Guidelines.\n\xef\x82\xb7\t National Pressure Ulcer Advisory Panel Guidelines.\n\xef\x82\xb7\t The New York State Department of Health, et al., Gold STAMP Program Pressure Ulcer Resource Guide,\n November 2012.\n7\n References used for this topic included:\n\xef\x82\xb7\t VHA Handbook 1142.01, Criteria and Standards for VA Community Living Centers (CLC), August 13, 2008.\n\xef\x82\xb7\t VHA Handbook 1142.03, Requirements for Use of the Resident Assessment Instrument (RAI) Minimum Data Set\n (MDS), January 4, 2013.\n\xef\x82\xb7\t Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument User\xe2\x80\x99s\n Manual, Version 3.0, May 2013.\n\xef\x82\xb7\t VHA Manual M-2, Part VIII, Chapter 1, Physical Medicine and Rehabilitation Service, October 7, 1992.\n\xef\x82\xb7\t Various requirements of The Joint Commission.\n8\n References used for this topic included:\n\xef\x82\xb7\t VHA Directive 2011-036, Safety and Health During Construction, September 22, 2011.\n\xef\x82\xb7\t VA Office of Construction and Facilities Management, Master Construction Specifications, Div. 1, \xe2\x80\x9cSpecial\n Sections,\xe2\x80\x9d Div. 01 00 00, \xe2\x80\x9cGeneral Requirements,\xe2\x80\x9d Sec. 1.5, \xe2\x80\x9cFire Safety.\xe2\x80\x9d\n\xef\x82\xb7\t Various Centers for Disease Control and Prevention recommendations and guidelines, Joint Commission\n standards, and Occupational Safety and Health Administration regulations.\n\n\n\n\nVA OIG Office of Healthcare Inspections 32\n\x0c"


type: caselaw

jurisdiction: EU

text:
 14.3.2022
 GA
 Iris Oifigiúil an Aontais Eorpaigh
 C 119/8
 Achomharc arna thabhairt an 14 Nollaig 2021 ag an gCoimisiún Eorpach i gcoinne bhreithiúnas na Cúirte Ginearálta (Naoú Dlísheomra méadaithe) a fógraíodh an 29 Meán Fómhair 2021 i gCás T-279/19, Front Polisario v An Chomhairle
 (Cás C-779/21 P)
 (2022/C 119/30)
 Teanga an cháis: an Fhraincis
 Tionscnaíodh an cás seo roimh an 1 Eanáir 2022, dáta deiridh an mhaolaithe ar an nGaeilge.


type: contracts

text:
 Důležité právní upozornění
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 22005A0908(01)
 Dohoda mezi Evropským společenstvím a vládou Ukrajiny o obchodu s některými výrobky z oceli - Dohodnutý zápis – Prohlášení – Protokol A
 Úřední věstník L 232 , 08/09/2005 S. 0043 - 0062
 Dohodamezi Evropským společenstvím a vládou Ukrajiny o obchodu s některými výrobky z oceliEVROPSKÉ SPOLEČENSTVÍ, dále jen "Společenství",na jedné straně aVLÁDA UKRAJINYna straně druhé,dále jen společně "strany",SE DOHODLY NA NÁSLEDUJÍCÍCH USTANOVENÍCH:Článek 11. Tato dohoda se použije pro obchod s výrobky z oceli uvedenými v příloze I, které pocházejí z Ukrajiny a ze Společenství.2. Obchod s výrobky z oceli uvedenými v příloze II může podléhat množstevním limitům.3. Obchod s výrobky z oceli, které nejsou uvedeny v příloze II, nepodléhá množstevním limitům.4. V případě výrobků z oceli a záležitostí, na něž se tato dohoda nevztahuje, se použijí příslušná ustanovení dohody o partnerství a spolupráci.Článek 21. Strany souhlasí se zavedením množstevních režimů, které stanoví limity uvedené v příloze III na vývoz výrobků uvedených v příloze II z Ukrajiny do Společenství, a s jejich zachováním po dobu platnosti této dohody. Tento vývoz podléhá systému dvojí kontroly, jak je uvedeno v protokolu A.2. Strany znovu zdůrazňují svůj závazek dosáhnout úplné liberalizace obchodu s výrobky z oceli uvedenými v příloze II, jakmile pro to budou vytvořeny podmínky.3. Strany souhlasí s tím, že se dovoz výrobků uvedených v příloze II z Ukrajiny do Společenství uskutečněný od 1. ledna 2005 do vstupu této dohody v platnost odečte od množstevních limitů uvedených v příloze III.4. Dovozy množství, která přesahují množství uvedená v příloze III, se povolují v případě, že průmysl Společenství není schopen uspokojit vnitřní poptávku, což vede k nedostatečné nabídce jednoho nebo více výrobků uvedených v příloze II. Na žádost kterékoli strany musí být na základě objektivních důkazů okamžitě zahájeny konzultace s cílem určit míru takového nedostatku. Na základě závěrů konzultací vydá Společenství pokyn k zahájení vnitřních postupů ke zvýšení množstevních limitů uvedených v příloze III.5. Kterákoli strana může kdykoli požádat o konzultace ohledně:- výše množstevních limitů stanovených v příloze III, pokud se podmínky týkající se výrobků uvedených v příloze výrazně zhoršily nebo zlepšily,- možnosti převodu nevyužitých množství uvedených v příloze III z nedostatečně využitých skupin výrobků do jiných skupin.Článek 31. Dovoz výrobků uvedených v příloze II na celní území Společenství za účelem propuštění do volného oběhu je podmíněn předložením dovozního povolení vydaného příslušným orgánem členského státu po předložení vývozní licence vydané ukrajinskými orgány a dokladu o původu v souladu s ustanoveními protokolu A.2. Dovoz výrobků uvedených v příloze II na celní území Společenství nepodléhá množstevním limitům uvedeným v příloze III, pokud jsou v rámci správního systému kontroly, jenž ve Společenství existuje, tyto výrobky prohlášeny za určené pro zpětný vývoz mimo Společenství v nezměněném stavu nebo po zpracování.3. Převod příslušných objemů množstevních limitů, které nebyly v kterémkoliv kalendářním roce využity, do následujícího kalendářního roku se pro danou skupinu výrobků a pro rok, v němž nebyly využity, povoluje do výše 10 % příslušných množstevních limitů uvedených v příloze III. Vláda Ukrajiny informuje Společenství nejpozději 31. března následujícího roku o tom, zda hodlá tohoto ustanovení využít.4. Se souhlasem obou stran může být až 15 % množstevního limitu stanoveného pro danou skupinu výrobků převedeno do jedné či více jiných skupin. Během kalendářního roku je možné u dané skupiny výrobků množstevní limit jednou upravit. Jakékoli úpravy množstevních limitů, ke kterým dochází v důsledku převodů, se dotýkají pouze právě probíhajícího kalendářního roku. Aniž jsou dotčena ustanovení výše uvedeného odstavce 3, odpovídá výše množstevních limitů na začátku následujícího kalendářního roku údajům uvedeným v příloze III. Ukrajina informuje Společenství nejpozději do 31. května o tom, zda hodlá tohoto ustanovení využít.Článek 41. S cílem učinit systém dvojí kontroly co nejúčinnější a s cílem minimalizovat možnosti zneužívání a obcházení předpisů:- informují orgány Společenství ukrajinské příslušné orgány, vždy k 28. dni každého měsíce, o dovozních povoleních vydaných během uplynulého měsíce,- informují ukrajinské příslušné orgány Společenství, vždy k 28. dni každého měsíce, o vývozních licencích vydaných během uplynulého měsíce.2. V případě jakéhokoli zásadního rozporu a s ohledem na časové faktory související s těmito informacemi může kterákoli strana požádat o konzultace, které musí být zahájeny okamžitě.3. Aniž je dotčen odstavec 1 a s cílem zajistit účinné fungování této dohody, souhlasí strany s tím, že učiní všechny nezbytné kroky, aby se zabránilo možnému obcházení předpisů, aby se všechny případy obcházení předpisů prošetřily a aby byla přijata všechna nezbytná právní nebo správní opatření proti obcházení předpisů, zejména proti překládce, přesměrování, nepravdivému prohlášení o zemi nebo místu původu, padělání dokumentů, nepravdivému prohlášení o množství, popisu nebo zařazení zboží. V návaznosti na to strany souhlasí se zavedením nezbytných právních ustanovení a správních postupů, které umožní podniknout proti takovému obcházení předpisů účinné kroky, jež budou zahrnovat přijetí právně závazných nápravných opatření proti dotčeným vývozcům nebo dovozcům.4. Pokud kterákoli ze stran dojde na základě dostupných informací k závěru, že je tato dohoda obcházena, může požádat druhou stranu o konzultace, jež musí být zahájeny okamžitě.5. Než budou k dispozici závěry konzultací podle odstavce 3, přijme vláda Ukrajiny preventivně, pokud ji o to Společenství požádá a existuje-li dostatek důkazů o tom, že došlo k obcházení předpisů, všechna nezbytná opatření s cílem zajistit, aby byly úpravy množstevních limitů, které mohou vyplynout z konzultací uvedených v odstavci 3, provedeny pro kalendářní rok, kdy byla podána žádost o konzultace podle odstavce 3, nebo pro rok následující, pokud byl limit pro daný kalendářní rok již vyčerpán.6. Pokud strany nebudou schopny dospět v průběhu konzultací uvedených v odstavci 3 k vzájemně uspokojivému řešení, má Společenství právo, pokud existuje dostatečný důkaz o tom, že při dovozu výrobků z oceli, na něž se vztahuje tato dohoda a které pocházejí z Ukrajiny, došlo k obcházení dohody, započítat příslušná množství do množstevních limitů stanovených v příloze III.7. Pokud strany nebudou schopny dospět v průběhu konzultací uvedených v odstavci 3 k oboustranně uspokojivému řešení a pokud existuje dostatečný důkaz o tom, že bylo učiněno nepravdivé prohlášení o množství, popisu nebo zařazení zboží, má Společenství právo dovoz dotčených výrobků odmítnout.8. Strany souhlasí s tím, že budou plně spolupracovat s cílem zabránit všem problémům vyplývajícím z obcházení této dohody a účinně je řešit.Článek 51. Množstevní limity na dovoz výrobků uvedených v příloze II do Společenství stanovené v rámci této dohody Společenství nerozdělí na regionální podíly.2. Strany spolupracují s cílem vyhnout se náhlým a škodlivým změnám v obvyklých obchodních tocích do Společenství. Pokud by k náhlé a škodlivé změně v obvyklých obchodních tocích (včetně regionální koncentrace nebo ztráty obvyklých zákazníků) došlo, má Společenství právo požádat o konzultace za účelem nalezení uspokojivého řešení tohoto problému. Takové konzultace se musí konat okamžitě.3. Vládá Ukrajiny usiluje o zajištění co nejrovnoměrnějšího ročního rozložení vývozu výrobků uvedených v příloze II do Společenství. Pokud by došlo k náhlé a škodlivé změně v dovozu, má Společenství právo požádat o konzultace za účelem nalezení uspokojivého řešení problému. Takové konzultace se musí konat okamžitě.4. Kromě povinnosti obsažené v odstavci 3 a aniž jsou dotčeny konzultace uvedené v čl. 2 odst. 5, může kterákoli strana, pokud licence vydané ukrajinskými orgány dosáhly 90 % množstevních limitů pro daný kalendářní rok, požádat o konzultace. Takové konzultace se musí konat okamžitě. Než budou k dispozici závěry těchto konzultací, mohou ukrajinské orgány nadále vydávat vývozní licence na výrobky uvedené v příloze II, pokud nepřekročí množství uvedená v příloze III.Článek 61. Pokud je z Ukrajiny do Společenství dovážen nějaký výrobek uvedený v příloze II za takových podmínek, že to způsobuje závažnou újmu výrobcům obdobných výrobků ve Společenství nebo taková újma hrozí, poskytne Společenství Ukrajině veškeré příslušné informace ve snaze najít oboustranně přijatelné řešení. Strany zahájí neprodleně konzultace.2. Pokud by se v rámci konzultací uvedených v odstavci 1 nepodařilo dosáhnout dohody do 30 dnů poté, co Společenství o konzultace požádalo, může Společenství podle ustanovení dohody o partnerství a spolupráci uplatnit své právo přijmout ochranná opatření.3. Bez ohledu na ustanovení této dohody se použijí ustanovení článku 19 dohody o partnerství a spolupráci.Článek 71. Zařazení výrobků, na které se vztahuje tato dohoda, vychází z celní a statistické nomenklatury Společenství (dále jen "kombinovaná nomenklatura" nebo zkráceně "KN"). Žádná změna kombinované nomenklatury učiněná v souladu s postupy platnými ve Společenství, co se týče výrobků uvedených v příloze II, ani žádné rozhodnutí týkající se zařazení zboží nesmí vést ke snížení množstevních limitů u výrobků uvedených v příloze III.2. Původ výrobků, na které se vztahuje tato dohoda, se určuje v souladu s platnými pravidly ve Společenství. Jakákoli změna těchto pravidel musí být oznámena vládě Ukrajiny a nesmí mít za následek snížení množstevních limitů této dohody. Postupy na kontrolu původu výše uvedených výrobků jsou stanoveny v protokolu A.Článek 81. Aniž je dotčena pravidelná výměna informací o vývozních licencích a dovozních povoleních podle čl. 4 odst. 1, souhlasí strany s tím, že si budou vyměňovat dostupné statistické údaje týkající se obchodu s výrobky uvedenými v příloze II, a to ve vhodných intervalech, přičemž je třeba vzít v úvahu nejkratší období přípravy takových informací; tyto údaje musí zahrnovat i vývozní licence a dovozní povolení vydaná podle článku 3 a dovozní a vývozní statistiky týkající se dotčených výrobků.2. Kterákoli strana může v případě jakéhokoli zásadního rozporu mezi vyměňovanými informacemi požádat o konzultace.Článek 91. Aniž jsou dotčena ustanovení týkající se konzultací, k nimž dochází v souvislosti se zvláštními okolnostmi, jak je uvedeno v předchozích článcích, konají se na žádost kterékoli strany konzultace o jakýchkoli problémech vyplývajících z uplatňování této dohody. Všechny konzultace se konají v duchu spolupráce a ve snaze sladit rozdíly mezi stranami.2. Pokud tato dohoda stanoví, že se konzultace musejí konat okamžitě, zajistí strany všemi možnými prostředky splnění této podmínky.3. Všechny ostatní konzultace se řídí těmito ustanoveními:- jakoukoli žádost o konzultace je třeba oznámit druhé straně písemně,- po žádosti musí případně v přiměřené lhůtě následovat zpráva udávající důvody konzultací,- konzultace budou zahájeny do jednoho měsíce ode dne obdržení žádosti,- konzultace by měly dospět k oboustranně přijatelnému závěru do jednoho měsíce od jejich zahájení, není-li toto období po dohodě obou stran prodlouženo.Článek 101. Tato dohoda vstupuje v platnost dnem svého podpisu. Je použitelná do 31. prosince 2006, s výhradou změn odsouhlasených oběma stranami a není-li vypovězena či ukončena v souladu s příslušnými ustanoveními odstavce 3 nebo 4.2. Kterákoli strana může kdykoli navrhnout změny této dohody, na nichž se musejí shodnout obě strany a které nabývají účinku dle vzájemné dohody obou stran.3. Kterákoli strana může tuto dohodu vypovědět, avšak s alespoň šestiměsíční výpovědní lhůtou. V takovém případě, nedohodnou-li se strany jinak, platnost dohody končí ke dni uplynutí výpovědní lhůty a limity stanovené touto dohodou se sníží poměrně ke dni, kdy vstoupí vypovězení dohody v platnost.4. V případě, že Ukrajina přistoupí k WTO před uplynutím platnosti této dohody, končí její platnost dnem přistoupení a k témuž dni se zruší množstevní limity.5. Společenství si vyhrazuje právo přijmout kdykoli veškerá vhodná opatření, včetně znovuzavedení systému autonomních celních kvót na vývoz výrobků uvedených v příloze II z Ukrajiny, pokud strany nejsou v rámci konzultací uvedených v předchozích článcích schopny dospět k oboustranně uspokojivému řešení nebo je-li dohoda kteroukoli stranou vypovězena.6. Přílohy I, II a III, prohlášení 1, 2, 3 a 4, dohodnutý zápis a protokol A, které jsou přiloženy k této dohodě, tvoří její nedílnou součást.Článek 11Tato dohoda je sepsána ve dvou vyhotoveních v jazyce anglickém, českém, dánském, estonském, finském, francouzském, italském, litevském, lotyšském, maďarském, maltském, německém, nizozemském, polském, portugalském, řeckém, slovenském, slovinském, španělském, švédském a ukrajinském, přičemž všechna znění mají stejnou platnost.Hecho en Bruselas, elV Bruselu dneUdfærdiget i Bruxelles denGeschehen zu Brüssel amBrüsselisΈγινε στις Βρυξέλλες, στιςDone at Brussels,Fait à Bruxelles, leFatto a Bruxelles, addi'Briselē,Priimta BriuselyjeKelt Brüsszelben,Magħmul fi Brussel,Gedaan te Brussel,Sporządzono w Brukseli, dniaFeito em Bruxelas,V BruseliV Bruslju,Tehty BrysselissäUtfärdat i Bryssel denВчинено в м.29-07-2005Por la Comunidad EuropeaZa Evropské společenstvíFor Det Europæiske FællesskabFür die Europäische GemeinschaftEuroopa Ühenduse nimelΓια την Ευρωπαϊκή ΚοινότηταFor the European CommunityPour la Communauté européennePer la Comunità europeaEiropas Kopienas vārdāEuropos bendrijos varduaz Európai Közösség részérőlGħall-Komunità EwropeaVoor de Europese GemeenschapW imieniu Wspólnoty EuropejskiejPela Comunidade EuropeiaZa Európske spoločenstvoZa Evropsko skupnostEuroopan yhteisön puolestaPå Europeiska gemenskapens vägnarЗа Eвропейське СпівтовариствоPor el Gobierno de UcraniaZa vládu UkrajinyFor Ukraines regeringFür die Regierung der UkraineUkraina valitsuse nimelΓια την Κυβέρνηση της ΟυκρανίαςFor the Government of UkrainePour le gouvernement ukrainienPer il governo dell'UcrainaUkrainas valdības vārdāUkrainos Vyriausybės varduUkrajna kormánya részérőlGħall-Gvern ta' l-UkrajnaVoor de regering van OekraïneW imieniu Rządu UkrainyPelo Governo da UcrâniaZa vládu UkrajinyZa Vlado UkrajineUkrainan hallituksen puolestaFör Ukrainas regeringЗа Уряд Украйни--------------------------------------------------