All Reports

Combined Assessment Program Summary Report - Construction Safety at Veterans Health Administration Facilities
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14-01288-145

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that inspections are completed at the designated frequency and by required members, that all required elements are documented, and that construction sites comply with applicable VA and Occupational Safety and Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that contractor tuberculosis risk assessments are conducted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that facilities establish Construction Safety Committees; develop and implement written policies addressing committee responsibilities; assure required committee membership and participation; and ensure meeting minutes include consistent documentation of inspection results, follow-up actions to resolve unsafe conditions, and tracking of actions to completion.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that Infection Control Committee meeting minutes include consistent documentation of construction-related infection control surveillance activities and any necessary follow-up actions to identified trends or problems.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that designated facility staff receive required initial and biennial construction safety training.
FY 2013 Review of VA's Compliance With the Improper Payments Elimination and Recovery Act
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13-02926-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended the Under Secretary for Health implement the corrective action plan included in the Performance and Accountability Report to reduce improper payments for the State Home Per Diem program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2014
We recommended the Under Secretary for Health develop achievable reduction targets for the State Home Per Diem and Beneficiary Travel programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2014
We recommended the Under Secretary for Benefits ensure thorough procedures for testing sample items used to estimate improper payments for the Compensation and Post 9/11 G.I. Bill programs.
Administrative Investigation, Failure to Comply with Americans with Disabilities Act and VA Policy, Veterans Health Administration
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13-02649-120

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2014
We recommend that the Deputy Under Secretary for Health Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2014
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommend that the DUSHOM confer with OGC and OHRI to determine and execute a plan to provide all VHA employees involved in the RA process, as well as Regional Counsels who provide them advice, the most up to date RA training and guidance, and direct all VHA employees to process RA requests in accordance with applicable Federal laws and regulations and VA policy.
Audit of VA's Pharmacy Reengineering Software Development Project
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12-04536-308

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure all of the time needed to develop and deploy each remaining Pharmacy Reengineering increment, to include the initial operating capability phase, is reported and monitored on the Project Management Accountability System Dashboard.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/18/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, develop guidance and a reliable methodology for capturing and reporting planned and actual project costs at the increment level on the Project Management Accountability System Dashboard for the remaining increments of Pharmacy Reengineering software development.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish guidance on replanning software development projects that have been paused in sufficient detail to demonstrate that increments of the projects are well thought out and achievable.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish controls to ensure information technology projects have sufficient leadership and staff assigned throughout the project life cycle.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/18/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish plans on how future Pharmacy Reengineering development will be funded until a decision is made regarding transferring this effort to the Integrated Electronic Health Record project.
Evaluation of VHA Community Based Outpatient Clinics Fiscal Year 2012
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13-00090-346

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
Ensure that CBOC clinicians document foot care education provided to diabetic patients in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians perform risk assessments and document risk levels for diabetic patients in the electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians document referrals for preventative foot care, including foot wear, as clinically indicated, for patients with diabetes in the electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to consistently link breast imaging and mammography results to the appropriate radiology mammogram or breast study order for all fee basis and contract patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to notify patients of normal mammogram results within the allotted timeframe and that notification is documented in the electronic health record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for privileging or re-privileging CBOC providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that facility Directors grant privileges consistent with the services provided at the CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that adequate resources and controls are in place to address deficiencies in the invoice validation process and to reduce the risk of overpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that the oversight of the contract acquisition process is compliant with VA Directives, including a thorough pre-award review and interim contract authority prior to contract approval.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that all new CBOCs undergo the required contract approval processes prior to initiating operations.
Audit of NCA's Contracting Practices
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12-00366-339

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure the Contracting Service establish procedures to ensure contracts are properly awarded according to the Federal Acquisition Regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure acquisition plans, market research, and evaluations of past performance are properly documented in the contract files.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure Contracting Service establish procedures to ensure competitive procurement methods are used to the maximum extent possible.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs coordinate with the Office of Acquisition, Logistics, and Management to resolve Electronic Contract Management System issues to ensure system capabilities are fully used.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 8/5/2014
We Recommend the Under Secretary for Memorial Affairs ensure Contracting Service fully implements the Integrated Oversight Process and ensure required contract reviews are conducted before awarding contracts.
Review of Alleged System Duplication in VA’s Virtual Office of Acquisition Software Development Project
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12-02708-301

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/18/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/8/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,000,000.00
Audit of VBA's Veterans' Retraining Assistance Program Participation
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12-04524-321

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they must monitor VA students' attendance and grades for satisfactory academic progress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they are required to report VA students' changes in enrollment to VBA within 30 days.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits revise the certifying official handbook to state a veteran's signed statement should not be used as the only means of verifying attendance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they need to accurately report credit hours and class terms in the VA ONline Certification of Enrollment system.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2014
We recommend the Under Secretary for Benefits include language on the Interactive Voice Response scripts to warn veterans of the potential penalty for certifying false enrollment information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2014
We recommend the Under Secretary for Benefits implement a plan to monitor veterans currently enrolled at the schools that had their approval withdrawn or suspended to ensure they meet Veterans Retraining Assistance Program full-time attendance requirements and are making positive progress towards program completion.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 12,000,000.00
Combined Assessment Program - Evaluation of Polytrauma Care in Veterans Health Administration Facilities
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12-01702-303

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health ensures that VHA performs a detailed analysis of workload and resource use to determine whether there is continued need for the numbers of sites at the current levels and whether changes in the requirements for dedicated polytrauma resources are needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that Level IV sites performing comprehensive TBI evaluations have approved alternate plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently complete TBI evaluations within 30 days of positive screens and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that the case management process meets requirements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that staff caring for polytrauma patients have the documented competencies required for caring for polytrauma patients and that compliance is monitored.
Vet Center Contracted Care Program Review
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12-00040-268

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders receive, review, and approve psychosocial assessments and counseling plans prior to authorizing contracted counseling services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct and document client assessments after 1 year of eligibility for contracted client services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct annual onsite quality reviews for contractors who participate in the Contract for Fee Program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service uses a standard template that includes terms and conditions that are consistent with those in the Readjustment Counseling Service policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service maintains and monitors counseling service contracts in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders authorize contracted counseling services in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
Healthcare Inspection - Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities
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13-01987-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2014
We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2014
We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities
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13-01189-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2014
We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Review of VA's Programs for Addressing Climate Change
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13-01846-235

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 4/2/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer coordinate with the Acting Assistant Secretary of the Office of Human Resources and Administration to implement existing telework expansion plans for reducing greenhouse gas emissions and to encourage VA employees to use alternative forms of commuting.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/17/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce greenhouse gas emissions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/17/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce fleet petroleum consumption.
Review of VA's Acquisitions Supporting the Veteran Employment Services Office
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13-00644-231

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 2/3/2015
We recommend the Acting Assistant Secretary for Human Resources and Administration improve the development and management of ADVANCE-funded acquisitions by strengthening the Strategic Management Group's process to fully assess program offices' procurement requests against VA's existing internal capacities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration take immediate action to assess veteran demand for call center services and modify the terms of its interagency agreement with the Office of Personnel Management to reflect anappropriate level of call center operations and related costs, including staffing resources.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration modify the Veteran Employment Services Office's interagency agreement with the Office of Personnel Management to require routine data reports on call centers' performance that include call volume, length of calls, blocked calls, wait times, and the overall accuracy of information provided to callers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration develop a process to independently assess the performance of the Veteran Employment Services Office's employment call centers by establishing metrics such as call volume, call wait times, hang-ups, and accuracy of information.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 3/31/2015
We recommend the Acting Assistant Secretary for Human Resources and Administration develop policy that prohibits the approval of modifications to interagency agreement terms that combine the costs and terms of distinct deliverables into one deliverable.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/14/2014
We recommend the Acting Assistant Secretary for Human Resources and Administration develop requirements to test and assess functions to be contracted to determine if these functions are inherently governmental as part of the acquisition planning process for all future contracts awarded to support the Veteran Employment Services Office's operations and initiatives.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,500,000.00
Combined Assessment Program Summary Report - Evaluation of Colorectal Cancer Screening and Follow-Up in Veterans Health Administration Facilities
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13-01741-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2015
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Combined Assessment Program Summary Report – Evaluation of Moderate Sedation in Veterans Health Administration Facilities
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13-01743-192

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.
Combined Assessment Program Summary Report – Evaluation of Nurse Staffing in Veterans Health Administration Facilities
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13-01744-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that all facilities fully implement the staffing methodology and complete all required steps.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that facilities improve processes to use the available data to manage and provide safe, cost-effective staffing.
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