text: b' Department of Veterans Affairs\n Office of Inspector General\n\n\n Office of Healthcare Inspections\n\nReport No. 14-00232-110\n\n\n Community Based Outpatient Clinic \n\n and Primary Care Clinic Reviews \n\n at \n\n VA Loma Linda Healthcare System \n\n Loma Linda, California \n\n\n\n\n\nMarch 31, 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 CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n Glossary\n AUD alcohol use disorder\n CBOC community based outpatient clinic\n DWHP designated women\xe2\x80\x99s health provider\n EHR electronic health record\n EOC environment of care\n FY fiscal year\n MH mental health\n MM medication management\n NIAAA National Institute on Alcohol Abuse and\n Alcoholism\n NM not met\n OIG Office of Inspector General\n PACT Patient Aligned Care Teams\n PCC primary care clinic\n PCP primary care provider\n PII personally identifiable information\n RN registered nurse\n VHA Veterans Health Administration\n VISN Veterans Integrated Service Network\n WH women\xe2\x80\x99s health\n\n\n\n\nVA OIG Office of Healthcare Inspections\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n Table of Contents \n\n Page \n\nExecutive Summary ................................................................................................... i\n\n\nObjectives, Scope, and Methodology....................................................................... 1\n\n Objectives ............................................................................................................... 1\n\n Scope...................................................................................................................... 1\n\n Methodology ........................................................................................................... 2\n\n\nResults and Recommendations ................................................................................ 3\n\n EOC ........................................................................................................................ 3\n\n AUD ........................................................................................................................ 5\n\n MM .......................................................................................................................... 7\n\n DWHP Proficiency .................................................................................................. 8\n\n\nAppendixes\n A. CBOC Profiles and Services Provided .............................................................. 9\n\n B. PACT Compass Metrics .................................................................................... 11\n\n C. VISN Director Comments .................................................................................. 15\n\n D. Facility Director Comments ............................................................................... 16\n\n E. OIG Contact and Staff Acknowledgments ......................................................... 20\n\n F. Report Distribution ............................................................................................. 21\n\n G. Endnotes ........................................................................................................... 22\n\n\n\n\n\nVA OIG Office of Healthcare Inspections\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n Executive Summary \n\nReview Purpose: The purpose of the review was to evaluate selected patient care\nactivities to determine whether the community based outpatient clinics (CBOCs) and\nprimary care clinics (PCCs) provide safe, consistent, and high-quality health care for our\nveterans. We conducted a site visit during the week of February 3, 2014, at the\nRancho Cucamonga, CA, CBOC which is under the oversight of the\nVA Loma Linda Healthcare System and Veterans Integrated Service Network 22:\n\nReview Results: We conducted four focused reviews and had no findings for the\nDesignated Women\xe2\x80\x99s Health Providers\xe2\x80\x99 Proficiency review. However, we made\nrecommendations in the following three review areas:\n\nEnvironment of Care. Ensure that:\n\n\xef\x82\xb7\t Personally identifiable information is protected by securing laboratory specimens\n during transport from the Rancho Cucamonga CBOC to the parent facility.\n\nAlcohol Use Disorder. Ensure that CBOC/PCC:\n\n\xef\x82\xb7\t Staff consistently complete diagnostic assessments for patients with a positive\n alcohol screen.\n\n\xef\x82\xb7\t Staff provide education and counseling for patients with positive alcohol screen and\n drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.\n\n\xef\x82\xb7\t Staff consistently document the offer of further treatment to patients diagnosed with\n alcohol dependence.\n\n\xef\x82\xb7\t Registered Nurse Care Managers receive motivational interviewing training within\n 12 months of appointment to Patient Aligned Care Teams.\n\nMedication Management. Ensure that CBOC/PCC staff:\n\n\xef\x82\xb7\t Document that medication reconciliation was completed at each episode of care\n where medications were administered, prescribed, or modified.\n\n\xef\x82\xb7\t Provide medication counseling/education that includes the fluoroquinolone.\n\n\n\n\nVA OIG Office of Healthcare Inspections i\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nComments\nThe VISN and Facility Directors agreed with the CBOC review findings and\nrecommendations and provided acceptable improvement plans. (See Appendixes C\nand D, pages 15-19, for the full text of the Directors\xe2\x80\x99 comments.) We will follow up on\nthe planned actions until they are completed.\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 CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n Objectives, Scope, and Methodology \n\nObjectives\nThe CBOC and PCC reviews are an element of the OIG\xe2\x80\x99s efforts to ensure that our\nNation\xe2\x80\x99s veterans receive high-quality VA health care services. As such, the CBOC and\nPCC reviews are recurring evaluations of selected primary care operations that focus on\npatient care quality and the EOC. In general, our objectives are to:\n\n \xef\x82\xb7\t Determine whether the CBOCs are compliant with EOC requirements.\n\n \xef\x82\xb7\t Determine whether CBOCs/PCCs are compliant with VHA requirements in the\n care of patients with AUD.\n\n \xef\x82\xb7\t Determine compliance with requirements for the clinical oversight and patient\n education of fluoroquinolones for outpatients.\n\n \xef\x82\xb7\t Evaluate if processes are in place for DWHPs to maintain proficiency in WH.\n\nScope\nTo evaluate for compliance with requirements related to patient care quality and the\nEOC, we conducted an onsite inspection, reviewed clinical and administrative records,\nand discussed processes and validated findings with managers and employees. The\nreview covered the following four activities:\n\n \xef\x82\xb7\t EOC\n\n \xef\x82\xb7\t AUD\n\n \xef\x82\xb7\t MM\n\n \xef\x82\xb7\t DWHP Proficiency\n\nThe scope of this review is limited to the established objectives. Issues and concerns\nthat come to our attention that are outside the scope of this standardized inspection will\nbe reviewed and referred accordingly.\n\n\n\n\nVA OIG Office of Healthcare Inspections 1\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nMethodology\nThe onsite EOC inspection was only conducted at a randomly selected CBOC that had\nnot been previously inspected.a Details of the targeted study populations for the AUD,\nMM, and DWHP Proficiency focused reviews are noted in Table 1.\n\nTable 1. CBOC/PCC Focused Reviews and Study Populations\n\n Review Topic Study Population\n AUD All CBOC and PCC patients screened within the study period\n of July 1, 2012, through June 30, 2013, and who had a positive\n AUDIT-C scoreb and all providers and RN Care Managers\n assigned to PACT prior to October 1, 2012.\n MM All outpatients with an original prescription ordered for one of\n the three selected fluoroquinolones from July 1, 2012, through\n June 30, 2013.\n DWHP Proficiencies All WH PCPs designated as DWHPs as of October 1, 2012,\n and who remained as DWHPs until September 30, 2013.\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\nThe review was done in accordance with OIG standard operating procedures for CBOC\nand PCC reviews.\n\n\n\n\na\n Includes 93 CBOCs in operation before March 31, 2013. \n\nb\n The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkers or have active \n\nalcohol use disorders. Scores range from 0\xe2\x80\x9312.\n\n\n\nVA OIG Office of Healthcare Inspections 2\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n Results and Recommendations \n\nEOC\nThe purpose of this review was to evaluate whether CBOC managers have established and\nmaintained a safe and clean EOC as required.1\n\nWe reviewed relevant documents and conducted a physical inspection of the\nRancho Cucamonga CBOC. The table below shows the areas reviewed for this topic. The area\nmarked as NM did not meet applicable requirements and needed improvement.\n\nTable 2. EOC\n\nNM Areas Reviewed Findings\n The CBOC\xe2\x80\x99s location is clearly identifiable\n from the street as a VA CBOC.\n The CBOC has interior signage available that\n clearly identifies the route to and location of\n the clinic entrance.\n The CBOC is Americans with Disabilities Act\n accessible.\n The furnishings are clean and in good repair.\n The CBOC is clean.\n The CBOC maintains a written, current\n inventory of hazardous materials and waste\n that it uses, stores, or generates.\n An alarm system and/or panic buttons are\n installed and tested in high-risk areas (e.g.,\n MH clinic).\n Alcohol hand wash or soap dispenser and\n sink are available in the examination rooms.\n Sharps containers are secured.\n Safety needle devices are available.\n The CBOC has a separate storage room for\n storing medical (infectious) waste.\n The CBOC conducts fire drills at least every\n 12 months.)\n Means of egress from the building are\n unobstructed.\n Access to fire alarm pull stations is\n unobstructed.\n Access to fire extinguishers is unobstructed.\n The CBOC has signs identifying the locations\n of fire extinguishers.\n Exit signs are visible from any direction.\n No expired medications were noted during the\n onsite visit.\n All medications are secured from\n unauthorized access.\n\n\nVA OIG Office of Healthcare Inspections 3\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nNM Areas Reviewed (continued) Findings\n X PII is protected on laboratory specimens Transport bags are not equipped with locking\n during transport so that patient privacy is devices to protect PII on laboratory specimens\n maintained. during transport from the Rancho Cucamonga\n CBOC to the parent facility.\n Adequate privacy is provided to patients in\n examination rooms.\n Documents containing patient-identifiable\n information are not laying around, visible, or\n unsecured.\n Window coverings provide privacy.\n The CBOC has a designated examination\n room for women veterans.\n Adequate privacy is provided to women\n veterans in the examination room.\n The information technology network\n room/server closet is locked.\n All computer screens are locked when not in\n use.\n Staff use privacy screens on monitors to\n prevent unauthorized viewing in high-traffic\n areas.\n EOC rounds are conducted semi-annually (at\n least twice in a 12-month period) and\n deficiencies are reported to and tracked by the\n EOC Committee until resolution.\n The CBOC has an automated external\n defibrillator.\n Safety inspections are performed on the\n CBOC medical equipment in accordance with\n Joint Commission standards.\n The parent facility includes the CBOC in\n required education, training, planning, and\n participation leading up to the annual disaster\n exercise.\n The parent facility\xe2\x80\x99s Emergency Management\n Committee evaluates CBOC emergency\n preparedness activities, participation in annual\n disaster exercise, and staff training/education\n relating to emergency preparedness\n requirements.\n\nRecommendation\n\n1. We recommended that managers ensure that PII is protected by securing laboratory\nspecimens during transport from the Rancho Cucamonga CBOC to the VA Loma Linda\nHealthcare System.\n\n\n\n\nVA OIG Office of Healthcare Inspections 4\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nAUD\nThe purpose of this review was to determine whether the facility\xe2\x80\x99s CBOCs and PCCs complied\nwith selected alcohol use screening and treatment requirements.2\n\nWe reviewed relevant documents. We also reviewed 38 EHRs and validated findings with key\nmanagers and staff. The table below shows the areas reviewed for this topic. The areas\nmarked as NM did not meet applicable requirements and needed improvement.\n\nTable 3. AUD\n\nNM Areas Reviewed Findings\n Alcohol use screenings are completed during\n new patient encounters, and at least annually.\n X Diagnostic assessments are completed for Staff did not complete diagnostic assessments\n patients with a positive alcohol screen. for 6 (16 percent) of 38 patients who had\n positive alcohol use screens.\n X Education and counseling about drinking Staff did not provide education and counseling\n levels and adverse consequences of heavy for 3 of 21 patients who had positive alcohol use\n drinking are provided for patients with positive screens.\n alcohol screens and drinking levels above\n NIAAA guidelines.\n X Documentation reflects the offer of further We did not find documentation of the offer of\n treatment for patients diagnosed with alcohol further treatment for three of six patients\n dependence. diagnosed with alcohol dependence.\n For patients with AUD who decline referral to\n specialty care, CBOC/PCC staff monitor them\n and their alcohol use condition.\n Counseling, education, and brief treatments\n for AUD are provided within 2 weeks of\n positive screening.\n X CBOC/PCC RN Care Managers have We found that 10 of 25 RN Care Managers did\n received MI training within 12 months of not receive MI training within 12 months of\n appointment to PACT. appointment to PACT.\n CBOC/PCC RN Care Managers have\n received National Center for Health Promotion\n and Disease Prevention approved health\n coaching training (most likely TEACH for\n Success) within 12 months of appointment to\n PACT.\n The facility complied with any additional\n elements required by VHA or local policy.\n\nRecommendations\n\n2. We recommend that CBOC/PCC staff consistently complete diagnostic assessments for\npatients with a positive alcohol screen.\n\n\n\n\nVA OIG Office of Healthcare Inspections 5\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n3. We recommended that that CBOC/PCC staff provide education and counseling for patients\nwith positive alcohol screen and drinking alcohol above NIAAA limits.\n\n4. We recommended that CBOC/PCC staff consistently document the offer of further\ntreatment to patients diagnosed with alcohol dependence.\n\n5. We recommended that CBOC/PCC RN Care Managers receive motivational interviewing\ntraining within 12 months of appointment to PACT.\n\n\n\n\nVA OIG Office of Healthcare Inspections 6\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nMM\nThe purpose of this review was to determine whether appropriate clinical oversight and\neducation were provided to outpatients prescribed oral fluoroquinolone antibiotics.3\n\nWe reviewed relevant documents. We also reviewed 38 EHRs and validated findings with key\nmanagers and staff. The table below shows the areas reviewed for this topic. The areas\nmarked as NM did not meet applicable requirements and needed improvement.\n\nTable 4. Fluoroquinolones\n\nNM Areas Reviewed Findings\n X Clinicians documented the medication We did not find documentation that medication\n reconciliation process that included the reconciliation included the newly prescribed\n fluoroquinolone. fluoroquinolone in 26 of 28 patient EHRs.\n Written information on the patient\xe2\x80\x99s prescribed\n medications was provided at the end of the\n outpatient encounter.\n X Medication counseling/education for the We did not find documentation of medication\n fluoroquinolone was documented in the counseling that included the fluoroquinolone in\n patients\xe2\x80\x99 EHRs. 18 (47 percent) of 38 patients\xe2\x80\x99 EHRs.\n Clinicians documented the evaluation of each\n patient\xe2\x80\x99s level of understanding for the\n education provided.\n The facility complied with local policy.\n\nRecommendations\n\n6. We recommended that staff document that medication reconciliation was completed at each\nepisode of care where the newly prescribed fluoroquinolone was administered, prescribed, or\nmodified.\n\n7. We recommended that staff provide medication counseling/education that includes the\nfluoroquinolone.\n\n\n\n\nVA OIG Office of Healthcare Inspections 7\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nDWHP Proficiency\nThe purpose of this review was to determine whether the facility\xe2\x80\x99s CBOCs and PCCs complied\nwith selected DWHP proficiency requirements.4\n\nWe reviewed the facility self-assessment, VHA and local policies, Primary Care Management\nModule data, and supporting documentation for DWHPs\xe2\x80\x99 proficiencies. The table below shows\nthe areas reviewed for this topic. The facility generally met requirements. We made no\nrecommendations.\n\nTable 5. DWHP Proficiency\n\nNM Areas Reviewed Findings\n CBOC and PCC DWHPs maintained\n proficiency requirements.\n CBOC and PCC DWHPs were designated\n with the WH indicator in the Primary Care\n Management Module.\n\n\n\n\nVA OIG Office of Healthcare Inspections 8\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n Appendix A\n\n\n CBOC Profiles \n\nThis review evaluates the quality of care provided to veterans at all of the CBOCs under the parent facility\xe2\x80\x99s oversight.c\nThe table below provides information relative to each of the CBOCs.\n\n Uniquesd Encountersd\n\n Station CBOC\n Location State Localitye MHg PCh Otheri All MHg PCh Otheri All\n # Sizef\n Palm Desert CA 605GC Urban Large 875 7,930 1,847 8,310 4,513 12,676 3,404 20,593\n Murrieta CA 605GB Rural Large 1,466 7,088 705 7,536 5,948 14,282 1,490 21,720\n Rancho\n CA 605GE Urban Large 1,238 4,949 625 5,258 7,408 9,793 1,677 18,878\n Cucamonga\n Victorville CA 605GA Urban Mid-Size 1,337 4,332 296 4,803 9,838 11,063 860 21,761\n Corona\n (Riverside CA 605GD Urban Mid-Size 860 3,461 96 3,811 4,569 7,512 310 12,391\n County), CA\n\xc2\xa0\n\n\n\n\nc\n Includes all CBOCs in operation before March 31, 2013. \n\nd\n Unique patients and Total Encounters \xe2\x80\x93 Source: MedSAS outpatient files; completed outpatient appointments indicated by a valid stop code during the \n\nJuly 1, 2012, through June 30, 2013, timeframe at the specified CBOC. \n\ne\n http://vaww.pssg.med.va.gov/PSSG/DVDC/FY2013_Q1_VAST.xlsx\n\nf\n Based on the number of unique patients seen as defined by VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, \n\nSeptember 11, 2008, the size of the CBOC facility is categorized as very large (> 10,000), large (5,000-10,000), mid-size (1,500-5,000), or small (< 1,500).\n\ng\n Mental Health includes stop codes in the 500 series, excluding 531 and 563, in the primary position. \n\nh\n Primary Care includes the stop code list in the primary position: 323 \xe2\x80\x93 Primary Care; 322 \xe2\x80\x93 Women\xe2\x80\x99s Clinic; 348 \xe2\x80\x93 Primary Care Group; 350 \xe2\x80\x93 Geriatric \n\nPrimary Care; 531 \xe2\x80\x93 MH Primary Care Team-Individual; 563 \xe2\x80\x93 Mental Health Primary care Team-Group; 170 \xe2\x80\x93 Home Based Primary Care (HBPC) Physician.\n\ni\n All other non-Primary Care and non-MH stop codes in the primary position.\n\n\nVA OIG Office of Healthcare Inspections 9\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n CBOC Services Provided \n\nIn addition to primary care integrated with WH and MH care, the CBOCs provide various\nspecialty care, ancillary, and tele-health services. The following table lists the services\nprovided at each CBOC.j\n\n Specialty\xc2\xa0Care\xc2\xa0 Tele-Health\n CBOC Ancillary\xc2\xa0Servicesl\n Servicesk Servicesm\n Palm Desert Palliative Care Audiology Tele Primary Care\n MOVE! Programn\n Diabetic Retinal Screening\n Murrieta --- MOVE! Program Tele Primary Care\n Diabetic Retinal Screening\n Rancho Cucamonga --- MOVE! Program Tele Primary Care\n Diabetic Retinal Screening\n Victorville --- MOVE! Program Tele Primary Care\n\n Corona (Riverside --- MOVE! Program ---\n County), CA\n\n\n\xc2\xa0\n\n\n\n\nj\n Source: MedSAS outpatient files; the denoted Specialty Care and Ancillary Services are limited to Primary Clinic \n\nStops with a count \xe2\x89\xa5 100 encounters during the July 1, 2012, through June 30, 2013, timeframe at the specified\n\nCBOC. \n\nk\n Specialty Care Services refer to non-Primary Care and non-Mental Health services provided by a physician. \n\nl\n Ancillary Services refer to non-Primary Care and non-Mental Health services that are not provided by a physician. \n\nm\n Tele-Health Services refer to services provided under the VA Telehealth program (http://www.telehealth.va.gov/) \n\nn\n VHA Handbook 1120.01, MOVE! Weight Management Program for Veterans, March 31, 2011. \n\n\nVA OIG Office of Healthcare Inspections 10\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n Appendix B\n\n\n PACT Compass Metrics\n\n\n\n\n\nData Definition.5 The average waiting time in days until the next third open appointment slot for completed primary care appointments in stop code 350.\nCompleted appointments in stop code 350 for this metric include completed appointments where a 350 stop code is in the primary position on the appointment or\none of the telephone stop codes is in the primary position, and 350 stop code is in the secondary position. The data is averaged from the national to the division\nlevel.\n\n\n VA OIG Office of Healthcare Inspections 11\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n\nData Definition.5 The percent of patients scheduled within 7 days of the desired date. Data source is the Wait Times Prospective Wait Times measures. The\ntotal number of scheduled appointments for primary care-assigned patients in primary care clinics 322, 323 and 350. Data is collected twice a month on the\n1st and the 15th. Data reported is for the data pulled on the 15th of the month. There is no FY to date score for this measure.\n\nVA OIG Office of Healthcare Inspections 12\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n\n Data efinition.5 This is a measure of where the patient receives his or her primary care and by whom. A low percentage is better. The formula is the total\n VHA ER/Urgent Care/FEE ER Encounters WOP (including FEE ER visits) divided by the number of primary care encounters WOP with the patient\xe2\x80\x99s\n assigned primary care (or associate) provider plus the total VHA ER/Urgent Care/FEE ER Encounters (including FEE ER visits) WOP plus the number of\n primary care encounters WOP with a provider other than the patient\xe2\x80\x99s PCP/AP.\n\nVA OIG Office of Healthcare Inspections 13\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\n\n\n Data Definition.5 Total Discharges Included in 2-day Contact Post Discharge Ratio: The total VHA and FEE Inpatient Discharges for assigned primary\n care patients for the reporting timeframe. Discharges resulting in death and discharges where a patient is readmitted within 2 days of discharge are excluded\n from this metric.\n\nVA OIG Office of Healthcare Inspections 14\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n Appendix C\n VISN Director Comments\n\n\n Department of\n Veterans Affairs Memorandum\n\n\n Date: March 25, 2014\n\n From: Director, Desert Pacific Healthcare Network (10N22)\n\n Subject: CBOC and PCC Review of the VA Loma Linda\n Healthcare System, Loma Linda, CA\n\n To: Director, Los Angeles Office of Healthcare Inspections\n (54LA)\n\n Director, Management Review Service (VHA 10AR MRS\n OIG CAP CBOC)\n\n\n\n 1. I concur with the findings and recommendations in the report of the\n CBOC and PCC Review of the VA Loma Linda Healthcare System,\n Loma Linda, CA.\n\n 2. \t If you have any questions regarding our responses and actions to the\n recommendations in the report, please contact me at (562) 826-5963.\n\n\n\n\nVA OIG Office of Healthcare Inspections 15\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n Appendix D\n Facility Director Comments\n\n\n\n Department of\n Veterans Affairs Memorandum\n\n\n Date: March 24, 2014\n\n From: Director, VA Loma Linda Healthcare System (605/00)\n\n Subject: CBOC and PCC Review of the VA Loma Linda\n Healthcare System, Loma Linda, CA\n\n To: Desert Pacific Healthcare Network (10N22)\n\n\n\n\n 1. I concur with the Loma Linda VA Medical Center\xe2\x80\x99s response and action\n\n plans as detailed within this report.\n\n\n\n\nVA OIG Office of Healthcare Inspections 16\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\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 managers ensure that PII is protected by\nsecuring laboratory specimens during transport from the Rancho Cucamonga CBOC to\nthe parent facility.\n\nConcur\n\nTarget date for completion: March 24, 2014\n\nFacility response: The facility has completed the re-training of all VHA and contract\ncouriers involved in the transport of laboratory specimens from the CBOC to the main\nlaboratory. Padlocks are now used to close specimen containers. Padlocks will be\nattached by the staff of the submitting location (CBOC) before the courier takes\npossession of the container. The Lab Specimen Tracking List has been updated\nclarifying steps for securing personal identifying information during transport. Staff have\nbeen trained on new process for securing containers during transport.\n\nRecommendation 2. We recommend that CBOC/PCC staff consistently complete\ndiagnostic assessments for patients with a positive alcohol screen.\n\nConcur\n\nTarget date for completion: July 31, 2014\n\nFacility response: The facility will educate the CBOC/Primary Care Clinic staff on VHA\nAudit C assessment requirements. Each day, a list of patients who have been\ndetermined to have had a positive Audit C screen, is uploaded onto a secured\nSharePoint site for CBOC/PCC Care Managers to obtain and follow up with an\nadditional assessment as warranted. Compliance will be determined through ongoing\nEHR review that will be reported to Quality Council quarterly.\n\nRecommendation 3. We recommended that CBOC/PCC staff provide education and\ncounseling for patients with positive alcohol screen and drinking alcohol above NIAAA\nlimits.\n\nConcur\n\nTarget date for completion: July 31, 2014\n\n\n\n\nVA OIG Office of Healthcare Inspections 17\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nFacility response: The facility will educate the CBOC/Primary Care Clinic staff on VHA\nAudit C education and counseling requirements and NIAAA drinking limits. Each day, a\nlist of patients who have been determined to have had a positive Audit C screen, is\nuploaded onto a secured SharePoint site for CBOC/PCC Care Managers to obtain and\nfollow up with an additional education and counseling. Compliance will be determined\nthrough ongoing EHR review that will be reported to Quality Council quarterly.\n\n\nRecommendation 4. We recommended that CBOC/PCC staff consistently document\nthe offer of further treatment to patients diagnosed with alcohol dependence.\n\nConcur\n\nTarget date for completion: July 31, 2014\n\nFacility response: The facility will educate the CBOC/Primary Care Clinic staff on VHA\nAudit C documentation requirements for further treatment options that are to be offered\nto patients diagnosed with alcohol dependence. Each day, a list of patient who have\nbeen determined to have had a positive Audit C screen, is uploaded onto a secured\nSharePoint site for CBOC/PCC Care Managers to obtain and follow up with notifying the\npatient of the additional treatment options. Compliance will be determined through\nongoing EHR review that will be reported to Quality Council quarterly.\n\n\nRecommendation 5. We recommended that CBOC/PCC RN Care Managers receive\nmotivational interviewing training within 12 months of appointment to PACT.\n\nConcur\n\nTarget date for completion: July 31, 2014\n\nFacility response: CBOC/PCC RN Care Managers will receive motivational\ninterviewing (MI) training within 12 months of appointment to PACT by adding MI\nTraining to the TMS Learning Plan and scheduling the training in the 2014 MI Training\nCalendar. Confirmation of attendance will occur at the time of the training, and those\nwho are scheduled but are not in attendance will be notified of the date and time of the\nnext MI training. Compliance will be audited every 6 months by completing a review of\nnewly hired RN Care Managers by pulling a report from TMS.\n\n\nRecommendation 6. We recommended that staff document that medication\nreconciliation was completed at each episode of care where the newly prescribed\nfluoroquinolone was administered, prescribed, or modified.\n\nConcur\n\nTarget date for completion: July 31, 2014\n\n\n\nVA OIG Office of Healthcare Inspections 18\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n\n\nFacility response: The facility will re-train physicians on the medication reconciliation\nprocess. This will include a review of the medication reconciliation policy in addition to\nspecific training related to fluoroquinolones and other antibiotics. Three training\nsessions will be held between now and June 15, 2014. The facility will conduct an EHR\nreview of patients who have been newly prescribed fluoroquinolones to determine\ncompliance with conducting medication reconciliation at the time of the patient\xe2\x80\x99s visit.\nThe audit results will be reported to Quality Council on a quarterly basis.\n\nRecommendation 7. We recommended that staff provide medication counseling/\neducation that includes the fluoroquinolone.\n\nConcur\n\nTarget date for completion: July 31, 2014\n\nFacility response: The facility will re-train staff, physicians and pharmacists on the\nneed to routinely perform and document medication counseling/education in EHR that\nspecifically includes newly prescribed fluroquinolones. The medication reconciliation\ntemplate will include the education/training provided to the patient regarding\nfluroquinolone use. The facility will conduct an EHR review to determine compliance\nwith documentation of counseling/education. The audit results will be reported to Quality\nCouncil on a quarterly basis.\n\n\n\n\nVA OIG Office of Healthcare Inspections 19\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\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 Yoonhee Kim, PharmD Team Leader\nContributors Kathleen Shimoda, BSN\n Jovie Yabes, RN\nOther Daisy Arugay, MT\nContributors Lin Clegg, PhD\n Matt Frazier, MPH\n Zhana Johnson, CPA\n Jeff Joppie, BS\n Jackelinne Melendez, MPA\n Jennifer Reed, RN, MSHI\n Simonette Reyes, RN\n Victor Rhee, MHS\n Patrick Smith, M. Stat\n Marilyn Stones, BS\n Mary Toy, RN, MSN\n Jarvis Yu, MS\n\n\n\n\nVA OIG Office of Healthcare Inspections 20\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n Appendix F\n\n Report Distribution\nVA Distribution\n\nOffice of the Secretary\nVeterans Health Administration\nAssistant Secretaries\nGeneral Counsel\nDirector, Desert Pacific Healthcare Network (10N22)\nDirector, VA Loma Linda Healthcare System (605/00)\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: Barbara Boxer, Dianne Feinstein\nU.S. House of Representatives: Ken Calvert, Paul Cook, Gary Miller,\n Gloria Negrete McLeod, Raul Ruiz, Mark Takano\n\n\nThis report is available at www.va.gov/oig.\n\n\n\n\nVA OIG Office of Healthcare Inspections 21\n\x0c CBOC and PCC Review at VA Loma Linda Healthcare System, Loma Linda, CA\n Appendix G\n\n Endnotes \n\n\n1\n References used for the EOC review included:\n\xef\x82\xb7\t US Access Board, Americans with Disabilities Act Accessibility Guidelines (ADAAG), September 2, 2002.\n\xef\x82\xb7\t US Department of Health and Human Services, Health Insurance Portability and Accountability Act, The\n Privacy Rule, August 14, 2002.\n\xef\x82\xb7\t US Department of Labor, Occupational Safety and Health Administration, Laws and Regulations.\n\xef\x82\xb7\t US Department of Labor, Occupational Safety and Health Administration, Guidelines for Preventing Workplace\n Violence, 2004.\n\xef\x82\xb7\t Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2013.\n\xef\x82\xb7\t VA Directive 0324, Test, Training, Exercise, and Evaluation Program, April 5, 2012.\n\xef\x82\xb7\t VA Directive 0059, VA Chemicals Management and Pollution Prevention, May 25, 2012.\n\xef\x82\xb7\t VA Handbook 6500, Risk Management Framework for VA Information System, September 20, 2012.\n\xef\x82\xb7\t VHA Center for Engineering, Occupational Safety, and Health, Emergency Management Program Guidebook,\n March 2011.\n\xef\x82\xb7\t VHA Center for Engineering, Occupational Safety, and Health, Online National Fire Protection Association\n Codes, Standards, Handbooks, and Annotated Editions of Select Codes and Standards, July 9, 2013.\n\xef\x82\xb7\t VHA Deputy Under Secretary for Health for Operations and Management, Memorandum: Environmental\n Rounds, March 5, 2007.\n\xef\x82\xb7\t VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011.\n\xef\x82\xb7\t VHA Directive 2012-026, Sexual Assaults & Other Defined Public Safety Incidents in VHA Facilities,\n September 27, 2012.\n\xef\x82\xb7\t VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004.\n\xef\x82\xb7\t VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010.\n\xef\x82\xb7\t VHA Handbook 1850.05, Interior Design Operations and Signage, July 1, 2011.\n2\n References used for the AUD review included:\n\xef\x82\xb7\t National Center for Health Promotion and Disease Prevention (NCP), Veteran Health Education and Information\n (NVEI) Program, Patient Education: TEACH for Success. Retrieved from\n http://www.prevention.va.gov/Publications/Newsletters/2013/HealthPOWER_Prevention_News_Winter_2012_2\n 013_FY12_TEACH_MI_Facilitator_Training.asp on January 17, 2014.\n\xef\x82\xb7\t VHA Handbook 1120.02, Health Promotion Disease Prevention (HPDP) Program, July 5, 2012.\n\xef\x82\xb7\t VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics,\n September 11, 2008.\n3\n References used for the Medication Management review included:\n\xef\x82\xb7\t VHA Directive 2011-012, Medication Reconciliation, March 9, 2011.\n\xef\x82\xb7\t VHA Directive 2012-011, Primary Care Standards, April 11, 2012.\n\xef\x82\xb7\t VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006.\n\xef\x82\xb7\t VHA Handbook 1108.07, Pharmacy General Requirements, April 17, 2008.\n\xef\x82\xb7\t Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2013.\n4\n References used for the DWHP review included:\n\xef\x82\xb7\t VHA Deputy Under Secretary for Health for Operations and Management, Memorandum: Health Care Services\n for Women Veterans, Veterans Health Administration (VHA) Handbook 1330.01; Women\xe2\x80\x99s Health (WH)\n Primary Care Provider (PCP) Proficiency, July 8, 2013.\n\xef\x82\xb7\t VHA Handbook 1330.01 Health Care Services for Women Veterans, May 21, 2010.\n\xef\x82\xb7\t VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.\n5\n Reference used for PACT Compass data graphs:\n\xef\x82\xb7\t Department of Veterans\xe2\x80\x99 Affairs, Patient Aligned Care Teams Compass Data Definitions, August 29, 2013.\n\n\n\n\nVA OIG Office of Healthcare Inspections 22\n\x0c'


type: contracts

jurisdiction: EU

text:
 19.3.2009
 EN
 Official Journal of the European Union
 L 73/50
 DECISION OF THE EEA JOINT COMMITTEE
 No 14/2009
 of 5 February 2009
 amending Annex XIII (Transport) to the EEA Agreement
 THE EEA JOINT COMMITTEE,
 Having regard to the Agreement on the European Economic Area, as amended by the Protocol adjusting the Agreement on the European Economic Area, hereinafter referred to as ‘the Agreement’, and in particular Article 98 thereof,
 Whereas:
 (1)
 Annex XIII to the Agreement was amended by Decision of the EEA Joint Committee No 129/2008 of 5 December 2008 (1).
 (2)
 Directive 2004/36/EC of the European Parliament and of the Council of 21 April 2004 on the safety of third-country aircraft using Community airports (2) was incorporated into the Agreement by Decision of the EEA Joint Committee No 152/2005 (3) of 2 December 2005, with country specific adaptations.
 (3)
 Commission Directive 2008/49/EC of 16 April 2008 amending Annex II to Directive 2004/36/EC of the European Parliament and of the Council regarding the criteria for the conduct of ramp inspections on aircraft using Community airports (4) is to be incorporated into the Agreement.
 (4)
 Commission Regulation (EC) No 351/2008 of 16 April 2008 implementing Directive 2004/36/EC of the European Parliament and of the Council as regards the prioritisation of ramp inspections on aircraft using Community airports (5) is to be incorporated into the Agreement,
 HAS DECIDED AS FOLLOWS:
 Article 1
 Annex XIII to the Agreement shall be amended as follows:
 1.
 the following indent shall be added in point 66r (Directive 2004/36/EC of the European Parliament and of the Council):
 ‘—
 32008 L 0049: Commission Directive 2008/49/EC of 16 April 2008 (OJ L 109, 19.4.2008, p. 17).’;
 2.
 the following point shall be inserted after point 66ra (Commission Regulation (EC) No 768/2006):
 ‘66rb.
 32008 R 0351: Commission Regulation (EC) No 351/2008 of 16 April 2008 implementing Directive 2004/36/EC of the European Parliament and of the Council as regards the prioritisation of ramp inspections on aircraft using Community airports (OJ L 109, 19.4.2008, p. 7).’
 Article 2
 The texts of Directive 2008/49/EC and Regulation (EC) No 351/2008 in the Icelandic and Norwegian languages, to be published in the EEA Supplement to the Official Journal of the European Union, shall be authentic.
 Article 3
 This Decision shall enter into force on 6 February 2009, provided that all the notifications under Article 103(1) of the Agreement have been made to the EEA Joint Committee (6).
 Article 4
 This Decision shall be published in the EEA Section of, and in the EEA Supplement to, the Official Journal of the European Union.
 Done at Brussels, 5 February 2009.
 For the EEA Joint Committee
 The President
 Alan SEATTER
 (1) OJ L 25, 29.1.2009, p. 36.
 (2) OJ L 143, 30.4.2004, p. 76.
 (3) OJ L 53, 23.2.2006, p. 53.
 (4) OJ L 109, 19.4.2008, p. 17.
 (5) OJ L 109, 19.4.2008, p. 7.
 (6) No constitutional requirements indicated.


type: wikipedia

text:
En o EN puede referirse también a:
 Siglas
 en, el código ISO 639-1 para el idioma inglés.
 La etilendiamina, líquido incoloro con olor a amoniaco que se disuelve en el agua formando una disolución de pH básico.
 Comité Europeo de Normalización (CEN), el órgano comunitario encargado de elaborar las normas EN, que definen los estándares europeos.
 Estonia (FIPS 10-4 y un obsoleto código de países de la OTAN).
 Electronegatividad, una medida de la capacidad de un átomo o molécula de atraer electrones en el contexto del enlace químico.
 Editorial Novaro, nombre de una editorial de cómics de México. Sus publicaciones se comercializaron en América Latina y España.
 Sumeria
 En o EN, cargo político en Sumeria, similar al rey de una ciudad, que luego evoluciona al ensi o patesi.
 Otros
 La preposición en.
 La letra en cirílica (Н, н).
 Enlaces externos
 Siglas


text:
 Avis juridique important
 |
 21980A1017(04)
 Agreement in the form of an exchange of letters between the European Economic Community and the Eastern Republic of Uruguay on trade in mutton and lamb
 Official Journal L 275 , 18/10/1980 P. 0037 - 0042 Finnish special edition: Chapter 3 Volume 12 P. 0171 Swedish special edition: Chapter 3 Volume 12 P. 0171 Greek special edition: Chapter 11 Volume 22 P. 0028
 ARRANGEMENT in the form of an exchange of letters between the European Economic Community and the Eastern Republic of Uruguay on trade in mutton and lamb Letter No 1 Sir, I have the honour to refer to the negotiations recently undertaken between our respective delegations for the purpose of drawing up provisions concerning import into the European Economic Community of mutton, lamb and goatmeat from Uruguay in connection with the implementation by the Community of the common organization of the market in sheepmeat and goatmeat. During these negotiations both parties agreed as follows: 1. This arrangement shall relate to: - fresh or chilled mutton, lamb and goatmeat (subheading 02.01 A IV a)) of the Common Customs Tariff), - frozen mutton, lamb and goatmeat (subheading 02.01 A IV b)) of the Common Customs Tariff). 2. Within the terms of this arrangement, the possibilities of export of mutton and lamb and goatmeat from Uruguay to the Community are fixed at the following annual quantity: 5 100 tonnes expressed in carcass weight (1). In order to ensure the proper functioning of the arrangement, Uruguay undertakes to implement the appropriate procedures to ensure that the annual quantity actually exported does not exceed the quantity agreed and shall be exported in accordance with the traditional patterns of presentation (frozen or chilled). Should changes in technology and trade make it possible to modify the presentational structure of trade, the two parties to this arrangement will consult each other prior to any such modification in the committee mentioned in clause 10 in order to find an adequate solution. 3. Should the Community have recourse to the safeguard clause, it undertakes that Uruguay's access to the Community as provided for in this arrangement will not be affected. 4. If imports from Uruguay in any one year exceed the quantities agreed, the Community reserves the right to suspend imports from Uruguay for the remainder of that year. The quantity overshipped shall be offset against Uruguay's export entitlement for the following year. 5. The Community undertakes to limit the levy applicable to imports of products covered by the present arrangement to a maximum amount of 10 %, ad valorem. (1)Carcass weight (bone-in equivalent weight). By this term is understood the weight of bone-in meat presented as such as well as boned meat converted by a coefficient into bone-in weight. For this purpose 55 kg of boned mutton corresponds to 100 kg of bone-in mutton and 60 kg of boned lamb corresponds to 100 kg of bone-in lamb. 6. At the time of accession of new Member States, the Community, in consultation with Uruguay, will alter the quantities set out in clause 2, in accordance with Uruguay's trade with each new Member State. The charges applicable to imports for the said new Member State shall be fixed in accordance with the rules in the Treaty of Accession ; the maximum level of the levy specified in clause 5 of this arrangement being taken into account. The total quantity as mentioned in clause 2 above is fixed at 5 800 tonnes in carcass weight as from the date of accession of Greece to the Community. 7. The Community will endeavour to avoid any market development which could prejudice the marketing of Uruguay's mutton and lamb on the Community market within the limits of the quantities agreed. In particular, the Community will take steps to ensure that the disposal of intervention stocks in frozen form arising from the operation of the regulation does not undermine such marketing of Uruguay's mutton and lamb. 8. In taking account of the objectives and provisions of this arrangement the Community agrees that any actual implementation of refunds of any other form of assistance with respect to exports of mutton, lamb and live sheep and lambs intended for slaughter will apply only at prices and on conditions which comply with existing international obligations and in respect of the traditional shares of the Community of world export trade in these products. These words shall be interpreted in a manner consistent with Article XVI of the General Agreement on tariffs and trade and in particular in conformity with Article 10 (2) (c) of the Agreement on interpretation and application of Articles VI, XVI and XXIII of the General Agreement on tariffs and trade. 9. Uruguay shall ensure that this arrangement is observed, in particular, by issuing export certificates covering the products referred to in clause 1 within the limits of the quantities covered by this arrangement. For its part, the Community shall undertake to adopt all necessary provisions to make the issue of the import certificates for the products referred to above, originating in Uruguay, subject to the presentation of an export certificate, issued by the competent authority designated by the Uruguay Government. Detailed rules for applying this system shall be laid down in such a way as to render unnecessary the lodging of a security for the issue of the import certificate in respect of the products in question. Also, such detailed rules of application shall provide that the competent Uruguay authority shall communicate periodically to the competent authority of the Community the quantities in respect of which export certificates are issued, broken down, where appropriate, according to destination. 10. A Consultative Committee shall be set up composed of representatives from the Community and from Uruguay. The Committee shall ensure that the arrangement is being properly applied and is functioning smoothly. It will examine regularly the trend of the two parties' markets in mutton and lamb and goatmeat and the trend of the international market, as well as marketing conditions on those markets including those relevant to the objective set out in clause 7 of this arrangement. It will ensure that the proper application of the arrangement is not affected by the export of mutton and lamb and goatmeat-based products to the Community under customs headings not referred to by the arrangement. The Committee will discuss all questions which could arise in applying the arrangement and will recommend appropriate solutions to the competent authorities. 11. The provisions of this arrangement shall be agreed without prejudice to the parties' rights and obligations under GATT. 12. The annual quantity fixed in clause 2 refers to the period running from 1 January to 31 December. The quantity applicable as of the implementation of the present arrangement and until 1 January of the following year will be fixed on a pro rata basis in relation to the total annual quantity and will take into account the seasonality of the trade. 13. This arrangement shall apply, on the one hand, to the territories in which the Treaty establishing the European Economic Community is applied and under the conditions laid down in that Treaty and, on the other hand, to the territory of the Eastern Republic of Uruguay. 14. The arrangement shall enter into force on 20 October 1980. It shall remain in force until 31 March 1984, and shall continue in force thereafter subject to each party having the right to denounce it by giving one year's notice in writing. In any case the provisions of this arrangement will be examined by the two parties before 1 April 1984 with a view to making any adjustment which they agree is necessary. I should be obliged if you would kindly confirm the agreement of your Government to the foregoing. Please accept, Sir, the assurance of my highest consideration. For the Council of the European Communities Letter No 2 Sir, I have the honour to acknowledge receipt of your letter of today's date, which reads as follows: "I have the honour to refer to the negotiations recently undertaken between our respective delegations for the purpose of drawing up provisions concerning import into the European Economic Community of mutton, lamb and goatmeat from Uruguay in connection with the implementation by the Community of the common organization of the market in sheepmeat and goatmeat. During these negotiations both parties agreed as follows: 1. This arrangement shall relate to: - fresh or chilled mutton, lamb and goatmeat (subheading 02.01 A IV a)) of the Common Customs Tariff), - frozen mutton, lamb and goatmeat (subheading 02.01 A IV b)) of the Common Customs Tariff). 2. Within the terms of this arrangement, the possibilities of export of mutton and lamb and goatmeat from Uruguay to the Community are fixed at the following annual quantity: 5 100 tonnes expressed in carcass weight (1). In order to ensure the proper functioning of the arrangement, Uruguay undertakes to implement the appropriate procedures to ensure that the annual quantity actually exported does not exceed the quantity agreed and shall be exported in accordance with the traditional patterns of presentation (frozen or chilled). Should changes in technology and trade make it possible to modify the presentational structure of trade, the two parties to this arrangement will consult each other prior to any such modification in the Committee mentioned in clause 10 in order to find an adequate solution. 3. Should the Community have recourse to the safeguard clause, it undertakes that Uruguay's access to the Community as provided for in this arrangement will not be affected. 4. If imports from Uruguay in any one year exceed the quantities agreed, the Community reserves the right to suspend imports from Uruguay for the remainder of that year. The quantity overshipped shall be offset against Uruguay's export entitlement for the following year. 5. The Community undertakes to limit the levy applicable to imports of products covered by the present arrangement to a maximum amount of 10 %, ad valorem. (1)Carcass weight (bone-in equivalent weight). By this term is understood the weight of bone-in meat presented as such as well as boned meat converted by a coefficient into bone-in weight. For this purpose 55 kg of boned mutton corresponds to 100 kg of bone-in mutton and 60 kg of boned lamb corresponds to 100 kg of bone-in lamb. 6. At the time of accession of new Member States, the Community, in consultation with Uruguay, will alter the quantities set out in clause 2, in accordance with Uruguay's trade with each new Member State. The charges applicable to imports for the said new Member States shall be fixed in accordance with the rules in the Treaty of Accession ; the maximum level of the levy specified in clause 5 of this arrangement being taken into account. The total quantity as mentioned in clause 2 above is fixed at 5 800 tonnes in carcass weight as from the date of accession of Greece to the Community. 7. The Community will endeavour to avoid any market development which could prejudice the marketing of Uruguay's mutton and lamb on the Community market within the limits of the quantities agreed. In particular, the Community will take steps to ensure that the disposal of intervention stocks in frozen form arising from the operation of the regulation does not undermine such marketing of Uruguay's mutton and lamb. 8. In taking account of the objectives and provisions of this arrangement the Community agrees that any actual implementation of refunds or any other form of assistance with respect to exports of mutton, lamb and live sheep and lambs intended for slaughter will apply only at prices and on conditions which comply with existing international obligations and in respect of the traditional shares of the Community of world export trade in these products. These words shall be interpreted in a manner consistent with Article XVI of the General Agreement on tariffs and trade and in particular in conformity with Article 10 (2) (c) of the Agreement on interpretation and application of Articles VI, XVI and XXIII of the General Agreement on tariffs and trade. 9. Uruguay shall ensure that this arrangement is observed, in particular, by issuing export certificates covering the products referred to in clause 1 within the limits of the quantities covered by this arrangement. For its part, the Community shall undertake to adopt all necessary provisions to make the issue of the import certificates for the products referred to above, originating in Uruguay, subject to the presentation of an export certificate, issued by the competent authority designated by the Uruguay Government. Detailed rules for applying this system shall be laid down in such a way as to render unnecessary the lodging of a security for the issue of the import certificate in respect of the products in question. Also, such detailed rules of application shall provide that the competent Uruguay authority shall communicate periodically to the competent authority of the Community the quantities in respect of which export certificates are issued, broken down, where appropriate, according to destination. 10. A Consultative Committee shall be set up composed of representatives from the Community and from Uruguay. The Committee shall ensure that the arrangement is being properly applied and is functioning smoothly. It will examine regularly the trend of the two parties' markets in mutton and lamb and goatmeat and the trend of the international market, as well as marketing conditions on those markets including those relevant to the objective set out in clause 7 of this arrangement. It will ensure that the proper application of the arrangement is not affected by the export of mutton and lamb and goatmeat-based products to the Community under customs headings not referred to by the arrangement.


text:
Is é an sóidiam dúil uimhir a 11, agus is í an tsiombail cheimiceach atá aige ná Na. "Natrium" a thugtar air ina lán teangacha, sa Ghearmáinis mar shampla. Is í an chumraíocht leictreonach atá aige ná 1s22s22p63s1. Is é sin, tá aon fhiúsleictreon amháin - an s-leictreon is dual do na miotail alcaileacha go léir - aige, agus ina chuid imoibriúchán leis na dúile eile, bíonn an sóidiam ag iarraidh an leictreon seo a thabhairt uaidh le hian deimhneach (Na+) a dhéanamh. Dá réir sin, is í an t-aon uimhir ocsaídiúcháin a bhíonn aige ina chuid comhdhúl ná +1.
 Ba é Sior Humphry Davy ba thúisce a d'aonraigh an sóidiam mar dhúil, nuair a chuir sé sruth leictreachais trí hiodrocsaíd sóidiam a bhí leáite. Níl sé éasca, áfach, sóidiam a choinneáil ina dhúil i bhfad, ós rud é go bhfuil sé chomh fonnmhar sin chun imoibriúcháin. Má bhíonn sé i dteagmháil dhíreach leis an aer, ocsaídeofar é, ionas go ndéanfar ocsaíd sóidiam Na2O nó sárocsaíd sóidiam Na2O2, agus má chuirtear san uisce é, cuirfidh sé bladhaire as agus é ag dul in áit na hidrigine san uisce, i gcruth is go dtiocfaidh hiodrocsaíd sóidiam as:
 2 Na + 2 H2O -> H2 + 2 NaOH
 Imoibriú eisiteirmeach, spontáineach atá i gceist leis seo, agus má chuirtear cuid mhór sóidiam san uisce in aon iarracht amháin, is féidir go mbeidh pléasc ann agus an t-uisce á stialladh ar fud na háite. Ós rud é go mbeidh an t-uisce sin lán hiodrocsaíd sóidiam ansin, fágfaidh sé cneácha loiscthe ar na daoine a bhuailfidh sé. An duine a bhainfidh triail as an imoibriú seo sa tsaotharlann, caithfidh sé a bheith an-chúramach. Mar sin, ní mór an sóidiam a choinneáil i dtaisce in ola nach ligeann don uisce ná don ocsaigin teacht in aon chóngar dó.
 In éineacht le hainiain na n-aigéad, cruthaíonn an sóidiam comhdhúile ianacha - salainn - a bhíonn so-thuaslagtha san uisce, cosúil leis an ngnáthshalann féin (clóiríd sóidiam, NaCl). Má chuirtear salann sóidiam trí thine, aithneofar ar dhath láidir buí na lasrach é, agus dá réir sin, baintear úsáid as an sóidiam i lampaí le solas buí a dhéanamh.
 Tá an sóidiam - i bhfoirm an iain Na+, ar ndóigh - an-choitianta sa dúlra. Mianraí sóidiam iad an salann, an hailít, an chrióilít, an t-amfaból, an tróna, an tseoilít, agus a lán eile. Tá sé ar fáil go flúirseach sna farraigí mar chlóiríd. Teastaíonn an sóidiam ó na horgánaigh bheo go léir, an duine san áireamh.
 Tá aon iseatóp cobhsaí amháin ag an sóidiam, is é sin, 23Na. Mar sin féin, bíonn rianta beaga de na hiseatóip úd 22Na (leathré: 2.605 bliain) agus 24Na (leathré timpeall ar cúig uair an chloig déag) ar fáil sa dúlra in áiteanna, ó ghintear iad faoi thionchar na radaíochta cosmaí.
 Tagairtí
 Dúile ceimiceacha


text:
 29.11.2014
 ET
 Euroopa Liidu Teataja
 L 344/3
 TÕLGE
 Euroopa Liidu ja Mali Vabariigi vaheline kirjavahetuse vormis
 LEPING
 Malis läbiviidava Euroopa Liidu ÜJKP missiooni (EUCAP Sahel Mali) Staatuse kohta
 Brüssel, 20. oktoober 2014
 Lugupeetud
 Ühise julgeoleku- ja kaitsepoliitika (ÜJKP) raames siiris liit 2013. aasta veebruaris sõjalise missiooni Mali relvajõudude väljaõppe toetamiseks (EUTM Mali). 2014. aasta aprillis siiris liit samal viisil tsiviilmissiooni (EUCAP Sahel Mali) Mali sisejulgeolekujõude toetamiseks. EUCAP Sahel Mali ja selle isikkoosseisu staatus määratakse kindlaks Euroopa Liidu ja Mali Vabariigi vahelise rahvusvahelise lepinguga.
 Nagu Te mäletate, sõlmis Mali Vabariik 4. aprillil 2013 lepingu EUTM Mali staatuse kohta Mali Vabariigis. Kõnealuse lepingu sätted vastavad mõningate eranditega täielikult EUCAP Sahel Mali vajadustele. Seetõttu teen ma Teile ettepaneku kohaldada EUCAP Sahel Mali suhtes kõiki kõnealuse lepingu sätteid (artiklid 1–19), välja arvatud artikli 1 lõike 3 punkt e ja artikli 13 lõiked 2–5, arvestades et:
 —
 mis tahes viidet EUTM Malile käsitatakse viitena EUCAP Sahel Malile;
 —
 artikli 1 lõike 3 punktis a asendatakse sõna „peakorter” sõnadega „EUCAP Sahel Mali peakorter”;
 —
 artikli 1 lõike 3 punktis c asendatakse mõiste „missiooni ülem” järgmise mõistega: „„missiooni juht” — EUCAP Sahel Mali juht kohapeal”;
 —
 artikli 9 lõikes 2 asendatakse sõnad „isikkoosseisu kuuluvad sõjaväelased” sõnaga „isikkoosseis”;
 —
 artikli 10 lõikes 3 asendatakse sõnad „vastuvõtva riigi enda relvajõududele” sõnadega „vastuvõtva riigi enda tsiviilteenistujatele või tsiviilisikutest koolitajatele”.
 Palun Teil mulle teada anda, kas olete nende ettepanekutega nõus.
 Teie positiivse vastuse korral moodustab käesolev kiri koos Teie vastusega õiguslikult siduva rahvusvahelise lepingu Euroopa Liidu ja Mali Vabariigi vahel EUCAP Sahel Mali staatuse kohta, mis jõustub Teie vastuse kättesaamise kuupäeval.
 Lugupidamisega
 Euroopa Liidu nimel
 Bamako, 31. oktoober 2014
 Lugupeetud
 Tänan teid 20. oktoobri 2014. aasta kirja eest, Mali Vabariigi territooriumil läbiviidava Euroopa Liidu ÜJKP missiooni (EUCAP Sahel Mali) staatuse kohta, mille sõnastus oli järgmine:
 „Ühise julgeoleku- ja kaitsepoliitika (ÜJKP) raames siiris liit 2013. aasta veebruaris sõjalise missiooni Mali relvajõudude väljaõppe toetamiseks (EUTM Mali). 2014. aasta aprillis siiris liit samal viisil tsiviilmissiooni (EUCAP Sahel Mali) Mali sisejulgeolekujõude toetamiseks. EUCAP Sahel Mali ja selle isikkoosseisu staatus määratakse kindlaks Euroopa Liidu ja Mali Vabariigi vahelise rahvusvahelise lepinguga.
 Nagu Te mäletate, sõlmis Mali Vabariik 4. aprillil 2013 lepingu EUTM Mali staatuse kohta Mali Vabariigis. Kõnealuse lepingu sätted vastavad mõningate eranditega täielikult EUCAP Sahel Mali vajadustele. Seetõttu teen ma Teile ettepaneku kohaldada EUCAP Sahel Mali suhtes kõiki kõnealuse lepingu sätteid (artiklid 1–19), välja arvatud artikli 1 lõike 3 punkt e ja artikli 13 lõiked 2–5, arvestades et:
 —
 mis tahes viidet EUTM Malile käsitatakse viitena EUCAP Sahel Malile;
 —
 artikli 1 lõike 3 punktis a asendatakse sõna „peakorter” sõnadega „EUCAP Sahel Mali peakorter”;
 —
 artikli 1 lõike 3 punktis c asendatakse mõiste „missiooni ülem” järgmise mõistega: „“missiooni juht” — EUCAP Sahel Mali juht kohapeal”;
 —
 artikli 9 lõikes 2 asendatakse sõnad „isikkoosseisu kuuluvad sõjaväelased” sõnaga „isikkoosseis”;
 —
 artikli 10 lõikes 3 asendatakse sõnad „vastuvõtva riigi enda relvajõududele” sõnadega „vastuvõtva riigi enda tsiviilteenistujatele või tsiviilisikutest koolitajatele”.
 Palun Teil mulle teada anda, kas olete nende ettepanekutega nõus.
 Teie positiivse vastuse korral moodustab käesolev kiri koos Teie vastusega õiguslikult siduva rahvusvahelise lepingu Euroopa Liidu ja Mali Vabariigi vahel EUCAP Sahel Mali staatuse kohta, mis jõustub Teie vastuse kättesaamise kuupäeval.”
 Teatan Teile, et olen Teie kirjas esitatud ettepanekutega nõus.
 Lugupidamisega
 Mali Vabariigi nimel


type: caselaw

text:
 18.4.2009
 ES
 Diario Oficial de la Unión Europea
 C 90/24
 Sentencia del Tribunal de Primera Instancia de 4 de marzo de 2009 — Associazione italiana del risparmio gestito y Fineco Asset Management/Comisión
 (Asunto T-445/05) (1)
 («Ayudas de Estado - Régimen de ayudas establecido por las autoridades italianas a favor de determinados organismos de inversión colectiva en valores mobiliarios especializados en acciones de sociedades de pequeña y mediana capitalización - Decisión por la que se declara la ayuda incompatible con el mercado común - Recurso de anulación - Afectación directa e individual - Admisibilidad - Obligación de motivación - Carácter selectivo de la medida - Obligación de recuperación»)
 2009/C 90/38
 Lengua de procedimiento: italiano
 Partes
 Demandantes: Associazione italiana del risparmio gestito y Fineco Asset Management SpA (Roma, Italia) (representantes: G. Escalar, G. Cipolla y V. Giordano, abogados)
 Demandada: Comisión de las Comunidades Europeas (representantes: V. Di Bucci y E. Righini, agentes)
 Objeto
 Anulación de la Decisión 2006/638/CE de la Comisión, de 6 de septiembre de 2005, relativa al régimen de ayudas ejecutado por Italia para determinados organismos de inversión colectiva en valores mobiliarios especializados en acciones de sociedades de pequeña y mediana capitalización cotizadas en mercados regulados (DO 2006, L 268, p. 1).
 Fallo
 1)
 Desestimar el recurso.
 2)
 Condenar en costas a las demandantes.
 (1) DO C 48, de 25.2.2006.


text:
Babócsay Izsák (írás-változatok: Babocsay Izsák, Babótsai Izsák) (17–18. század) jegyző.
 Tarcal városának jegyzője. 1695-től vagy előbb is a tarcali fiskális szőlők inspektora is volt egyúttal. 1705-ben veje, Héczey István vette át hivatalát, mivel ekkor már betegágyban fekvő idős ember volt. Valószínűleg ezután nem sokkal elhunyt. Munkája egyik kéziratához csatolt jegyzetéből tudni, hogy 1702-ben 56-ik évében járt.
 A Tarcal város 17. század végi történetéről írt munkát Rumy Ferenc Monumenta Hungarica című gyűjteménye I. kötetében Pesten 1815-ben adta ki a sárospataki kollégium könyvtárában létező másolat után Kazinczy Ferenc kéziratából: Fata Tarczaliensia, azaz Tarczal városának főbb változásai (1670–1700). Rumy történeti és nyelvészeti magyarázatokkal látta el a művet. Szirmay Antal Historia Comitatus Zempliniensis című munkájában ismertette. Egykorú és későbbi másolatai megvannak az Országos Széchényi Könyvtár kézirattárában.
 A munkájában tárgyalt három évtizedben áldatlan állapotok uralkodtak Tarcalon és a Felső-Tisza vidékén. 1680-ban Tarcal behódolt Egernek és évi adót fizetett a töröknek, mert sehol sem volt „Istenen kivül semmi oltalombeli bizodalom”. Néhány év múlva „az idegen német nemzet vas jármába szorúl a lakosság nyaka”. Ezekből az évekből sok fontos adatot őrzött meg az utókornak a tarcali jegyző. Kazinczyék „gyilkolónak” nevezték stílusát, de ma már fölösleges lenne a kényes irodalmi ízlés szempontjából elbírálni Babocsay munkáját.
 Források
 Angyal Dávid (szerk. Beöthy Zsolt) Képes magyar irodalomtörténet (35. Történetirodalmunk a XVIII. század elején című fejezet), Budapest, 1896; (DVD-n: Arcanum Kiadó)
 Magyar történetírók
 17. századi magyarok


text:
 Avis juridique important
 |
 22002D0140(01)
 Decisão do Comité Misto do EEE n.° 140/2002, de 8 de Novembro de 2002, que altera o anexo II (regulamentação técnica, normas, ensaios e certificação) e o Protocolo n.° 37 do Acordo EEE
 Jornal Oficial no L 019 de 23/01/2003 p. 0005 - 0006
 Decisão do Comité Misto do EEEn.o 140/2002de 8 de Novembro de 2002que altera o anexo II (regulamentação técnica, normas, ensaios e certificação) e o Protocolo n.o 37 do Acordo EEEO COMITÉ MISTO DO EEE,Tendo em conta o Acordo sobre o Espaço Económico Europeu, tal como alterado pelo Protocolo que adapta o Acordo sobre o Espaço Económico Europeu, a seguir designado "o acordo", e, nomeadamente, os seus artigos 98.o a 101.o,Considerando o seguinte:(1) O anexo II do acordo foi alterado pela Decisão do Comité Misto do EEE n.o 125/2002, de 27 de Setembro de 2002(1).(2) O Protocolo n.o 37 do acordo foi alterado pela Decisão do Comité Misto do EEE n.o 83/1999 de 25 de Junho de 1999(2).(3) O Regulamento (CE) n.o 141/2000 do Parlamento Europeu e do Conselho, de 16 de Dezembro de 1999, relativo aos medicamentos órfãos(3), foi incorporado no acordo pela Decisão do Comité Misto n.o 68/2001(4).(4) Os Estados da EFTA envolvidos devem ser associados aos trabalhos do Comité dos Medicamentos Órfãos.(5) É necessário alterar o Protocolo n.o 37 do acordo, que enumera os comités a cujos trabalhos os especialistas dos Estados da EFTA serão associados, sempre que o bom funcionamento do acordo assim o exija.(6) É necessário alterar o anexo II do acordo em conformidade com a alteração do Protocolo n.o 37, a fim de especificar as modalidades de associação,DECIDE:Artigo 1.oNo Protocolo n.o 37 do acordo (que contém a lista referida no artigo 101.o) é inserido o seguinte ponto:"14. 'Comité dos Medicamentos Órfãos' [Regulamento (CE) n.o 141/2000 do Parlamento Europeu e do Conselho].".Artigo 2.oNo capítulo XIII do anexo II do acordo, ao ponto 15m [Regulamento (CE) n.o 141/2000], é aditado o seguinte: "Para efeitos do presente acordo, as disposições do regulamento passam a ter a seguinte redacção:Os Estados da EFTA devem ser integralmente associados aos trabalhos do Comité dos Medicamentos Órfãos. As modalidades de participação dos representantes dos Estados da EFTA estarão em conformidade com as disposições do artigo 4.o do regulamento. Todavia, esses representantes não participarão na votação e as suas posições serão lavradas em acta separadamente. O lugar de presidente estará reservado a um membro nomeado por um Estado-Membro da Comunidade. O regimento interno do referido comité será alterado, a fim de ter plenamente em conta a participação dos Estados da EFTA.Os Estados da EFTA contribuirão financeiramente para os trabalhos do Comité em conformidade com o n.o 1, alínea a), do artigo 82.o do Acordo EEE.".Artigo 3.oA presente decisão entra em vigor em 9 de Novembro de 2002, desde que tenham sido efectuadas ao Comité Misto do EEE todas as notificações previstas no n.o 1 do artigo 103.o do acordo(5).Artigo 4.oA presente decisão será publicada na secção EEE e no suplemento EEE do Jornal Oficial das Comunidades Europeias.Feito em Bruxelas, em 8 de Novembro de 2002.Pelo Comité Misto do EEEO PresidenteKjartan Jóhannsson(1) JO L 336 de 12.12.2002, p. 23.(2) JO L 296 de 23.11.2000, p. 41.(3) JO L 18 de 22.1.2000, p. 1.(4) JO L 238 de 6.9.2001, p. 14.(5) Requisitos constitucionais indicados.