All Reports

Healthcare Inspection – Unexpected Death of a Patient During Treatment with Multiple Medications, Tomah VA Medical Center, Tomah, WI
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15-02131-471

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Acting Veterans Integrated Service Network Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2016
We recommended that the Acting Facility Director ensure compliance with VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures as it relates to medication administration.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2016
We recommended that the Acting Facility Director review all elements needed to respond effectively to medical emergencies including staff training, equipment, and other resources at both the unit and the facility level and take any appropriate actions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommended that the Acting Facility Director review and evaluate medications currently available on emergency crash carts, including but not limited to, reversal agents for narcotic and/or benzodiazepine toxicity and make changes as appropriate.
Review of Alleged Mismanagement of VHA's Service-Oriented Architecture Research and Development Pilot Project
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14-00545-343

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended the Under Secretary for Health establish an oversight mechanism to ensure the use of proper appropriations for Veterans Health Administration information technology projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended the Under Secretary for Health remedy all Medical Support and Compliance appropriations used to pay for Service-Oriented Architecture Research and Development.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended the Under Secretary for Health confer with VA’s Office of Accountability Review regarding administrative actions against Veterans Health Administration senior officials, beyond those individuals who have left VA employment, who were involved with Service-Oriented Architecture Research and Development funding decisions and ensure that action is taken, if appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/16/2016
We recommended the Executive in Charge, Office of Information and Technology, obtain Chief Financial Officer certifications from responsible VA Administrations or Staff Offices that proper appropriations will be used before using any non-Information Technology Systems appropriations for any information technology project, including projects managed by the Project Management Accountability System.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,600,000.00
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Mann-Grandstaff VA Medical Center, Spokane, Washington
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15-00139-451

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that panic buttons are tested and that testing is documented at the Wenatchee Community Based Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Facility Director identifies a Lead Human Immunodeficiency Virus Clinician to carry out required responsibilities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Inspection of VA Regional Office Cleveland, Ohio
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14-04983-412

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended the Cleveland VA Regional Office Director conduct a review of the 880 temporary 100 percent disability evaluations remaining from their universe as of October 8, 2014, and take appropriate actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended the Cleveland VA Regional Office Director provide training on prioritizing temporary 100 percent disability evaluation claims and assess the effectiveness of that training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended the Cleveland VA Regional Office Director certify that corrective action has been accomplished for the seven cases still requiring action from our September 2012 inspection.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2016
We recommended the Cleveland VA Regional Office Director implement a plan to monitor the effectiveness of training on traumatic brain injury claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2016
We recommended the Cleveland VA Regional Office Director implement a plan to ensure staff comply with Veterans Benefits Administration's second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing to identify local training needs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2016
We recommended the Cleveland VA Regional Office Director implement a plan to assess the effectiveness of the recent special monthly compensation training and continue to provide refresher training on higher levels of special monthly compensation and ancillary benefits.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended the Cleveland VA Regional Office Director implement a plan to provide refresher training to staff on establishing accurate dates of claim in the Veterans Benefits Administration's electronic systems of record and assess the effectiveness of the training.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended the Cleveland VA Regional Office Director implement a plan to ensure staff establish accurate dates of claim in the Veterans Benefits Administration's electronic systems of record.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2016
We recommended the Cleveland VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Healthcare Inspection – Review of the Operations and Effectiveness of VHA Residential Substance Use Treatment Programs
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15-01579-457

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that Mental Health Services liaison with internal and external entities regarding standardized data collection from screening processes to core outcome measures to improve program monitoring and by which Mental Health Services can develop collaborative treatment initiatives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that Mental Health Services ensure system-wide use of the 596 stop code.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that Mental Health Services review the consistency of current processes and provides specific guidance on reducing inflow of contraband into residential substance use treatment programs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2016
We recommended that Mental Health Services consider requiring programs to document patients' physical status in addition to presence when completing physical bed checks.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2016
We recommended that Mental Health Services clarify the intent of the requirement for and use of closed circuit television with respect to residential substance use programs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that Mental Health Services review and evaluate whether reversal agents such as naloxone are readily available at each residential substance use treatment program.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that Mental Health Services encourage more widespread incorporation of programming with a specialized focus on mental health comorbidities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that Mental Health Services encourage discussion of addiction focused pharmacotherapy with residential substance use treatment program patients.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that Mental Health Services ensure that active mental health comorbidities are addressed in residential substance use rehabilitation treatment program interdisciplinary treatment plans.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that Mental Health Services ensure documentation of post-discharge aftercare appointment arrangements for mental health comorbidities.
Healthcare Inspection – Mental Health-Related Deficiencies and Inadequate Leadership Responsiveness, Central Alabama VA Health Care System, Montgomery, Alabama
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14-04530-414

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure adequate mental health staffing in the community based outpatient clinics to provide timely and appropriate patient care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure appropriate review and scheduling of patients on the electronic wait list and Recall Reminder lists provided to management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that staff are trained on the proper use and management of the electronic wait list and the Recall Reminder list, that recall reminder letters are sent to patients, and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that clinical staff and the Suicide Prevention program staff follow guidelines on the identification, tracking, treatment, and follow-up of patients at high risk for suicide.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that Substance Abuse Treatment Program patients have more timely access to residential/domiciliary beds, as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that staff receive appropriate training on the policy requirements for managing disruptive behavior.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that the Disturbed Behavior Committee complies with policy on completing and documenting incident/threat assessments and initiating Patient Record Flags.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that all Disturbed Behavior Committee Alert Notes, both recent and remote, have been reviewed and appropriate actions taken, if indicated.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure behavioral Patient Record Flags are re-evaluated within established timeframes.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director evaluate options available to improve the timeliness of Emergency Department clearance and acute mental health unit admission for high risk patients.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2017
We recommended that the Central Alabama VA Health Care System Director ensure that mental health providers adequately document their clinical reasoning when their treatment decisions do not comply with VA/DoD guidelines for medication management in Post-Traumatic Stress Disorder and Substance Use Disorder patients.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director approve and issue a Mental Health Treatment Coordinator policy and train appropriate staff on same.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2017
We recommended that the Central Alabama VA Health Care System Director ensure assignment of Mental Health Treatment Coordinators for all appropriate patients.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director monitor to ensure the Dothan Primary Care contractor complies with staffing and care specifications as outlined in the contract.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director ensure that the Dothan Primary Care contract complies with Veterans Health Administration policy on the treatment of uncomplicated psychiatric disorders.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director update the Dothan Mental Health Community Based Outpatient Clinics recorded message to instruct callers on what to do for a mental health emergency and how to access the Suicide Prevention/Crisis lines.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama VA Health Care System Director reinitiate ongoing professional practice evaluation-related mental health chart reviews.
Healthcare Inspection - Deficient Consult Management, Contractor, and Administrative Practices, Central Alabama VA Health Care System, Montgomery, Alabama
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14-04530-452

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2016
We recommended that the Under Secretary for Health provide consistent interim leadership to Central Alabama Veterans Health Care System in the form of highly skilled leaders who can lead systemic improvements and cultural change until such time as the leadership positions can be filled permanently.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2019
We recommended that the Under Secretary for Health directly monitor corrective actions taken to remedy the deficiencies identified in this report and routinely assess their effectiveness at least annually for a period of 3 years.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2016
We recommended that interim Central Alabama Veterans Health Care System leadership begin, and permanent leadership continue, to make systemic improvements to the Non-VA Care Coordination consult process, to include ensuring that patients receive services timely; that the backlog is resolved; that staff comply with business rules governing the process; and that the program is provided with adequate staffing, training, and a consistent leadership structure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended that the interim Central Alabama Veterans Health Care System leadership develop processes to ensure that Human Resource tracking and reporting is accurate and that Central Alabama Veterans Health Care System either has adequate staffing to meet patient care needs in a timely manner or adequate processes to ensure patients receive timely care in the community.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended that the interim Central Alabama Veterans Health Care System leadership identify opportunities to improve system integration between the Montgomery campus, the Tuskegee campus, and the community based outpatient clinics, to include evaluating the need for dedicated community based outpatient clinic coordinators.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended that the interim Central Alabama Veterans Health Care System leadership ensure that the system Administrative Boards of Investigation policy reflects all required elements outlined in the Veterans Health Administration Handbook.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2016
We recommended that the interim Central Alabama Veterans Health Care System leadership ensure that all previously chartered Administrative Boards of Investigations have been conducted and finalized to include documentation of decision for final action(s), evidence that actions have been implemented and/or addressed, and appropriate certification of completion per Veterans Health Administration guidelines.
Inspection of VA Regional Office Louisville, Kentucky
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15-01193-433

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/14/2015
We recommended the Louisville VA Regional Office Director develop and implement a plan to ensure staff follows policies and procedures associated with scheduling medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/14/2015
We recommended the Louisville VA Regional Office Director conduct a review of the 345 temporary 100 percent disability evaluations remaining from our inspection universe as of December 10, 2014, and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/14/2015
We recommended the Louisville VA Regional Office Director develop and implement a plan to assess the effectiveness of higher-level Special Monthly Compensation training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/14/2015
We recommended the Louisville VA Regional Office Director develop and implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/14/2015
We recommended the Louisville VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Combined Assessment Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington
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15-00599-438

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that the Critical/Acute Care and Transfusion Committee review each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that the committee collects code data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that the Surgical Quality Committee meet monthly, document its review of National Surgical Office reports, and review all surgical deaths with identified problems or opportunities for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2015
We recommended that the facility keep the recipient list for the critical incident automated e-mail notification current.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that the recently initiated Accident Review Board provide oversight of the safe patient handling program and gather, track, and share patient handling injury data.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2015
We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2015
We recommended that Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2015
We recommended that facility managers ensure fire extinguishers in all patient care areas have documented monthly safety checks and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2015
We recommended the facility complete and document an annual review of the Hazard Vulnerability Assessment.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2015
We recommended that nursing reviewers sign the monthly medication inspection forms for the intensive care and inpatient general medicine units and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that employees consistently post patients’ advance directives status correctly and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the intensive care unit.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2015
We recommended that the facility revise the emergency airway management policy to include the type of clinical staff whose expected duties would include emergency airway management.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required components and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2016
We recommended that facility managers ensure video laryngoscopes are available for immediate clinician use and monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2015
We recommended that the facility ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
Healthcare Inspection – Delay in Emergency Airway Management and Concerns about Support for Nurses, VA Northern California Health Care System, Mather, CA
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15-00533-440

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the Facility Director ensure that staff provide patients information on and assistance with completing advance directives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2015
We recommended that the Facility Director ensure that corrective action plans concerning clinical warnings, including code status, on patients' wristbands are fully implemented and that managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2015
We recommended that the Facility Director instruct nurse managers to conduct an inspection and ongoing monitoring of all inpatient units to ensure nurses do not make copies of wristbands for medication administration.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the Facility Director conduct an evaluation of the medical-surgical unit to determine if there are issues undermining psychological safety at the work place and take action to address those issues.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the Facility Director develop and implement a plan for employee support following traumatic events.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
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15-00130-432

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Kenosha CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that Clinic Registered Nurse Care Managers and providers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their abnormal laboratory results.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central Texas Veterans Health Care System, Temple, Texas
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15-00132-430

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2016
We recommended that the staff at theBrownwood CBOC receive regular information/updates on their responsibilities in emergency response operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2016
We recommended that clinic staffconsistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that ClinicRegistered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that providers in theoutpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Iowa City VA Health Care System, Iowa City, Iowa
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15-00144-426

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2016
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results include all required elements
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
|
15-00598-446

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2015
We recommended that the Medical Emergency Committee review each code episode.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Accident Review Board Committee share patient handling injury data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2015
We recommended that the quality control policy/process for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the facility clean and/or repair soiled and/or damaged wheelchairs in patient care areas or remove them from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Controlled Substances Coordinator provide quarterly trend reports to the Facility Director.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that controlled substances inspectors consistently inspect all required non-pharmacy areas with controlled substances and that the Controlled Substances Coordinator monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that facility managers ensure the Controlled Substances Coordinator sufficiently rotates controlled substances inspectors in inspection assignments and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that controlled substances inspectors complete inspections on the same day initiated and that the Controlled Substances Coordinator monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that the Facility Director ensure that the controlled substances inspection program has adequate oversight and complies with Veterans Health Administration policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that Domiciliary Care for Homeless Veterans Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas
|
15-00596-429

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, and a complete review of scanned documents to ensure readability and retrievability.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently document actions when data analyses indicated problems or opportunities for improvement and evaluate them for effectiveness in the Quality, Safety, and Value; Critical Care; Medical Records; and Infection Prevention and Control Committees and in the Environment of Care Council.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees offer patients the opportunity to review, revise, or rescind previously completed advance directives and document the discussions and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that respiratory therapy employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include an alternative for new employees, transfers from other VA medical centers, consultants or without compensation clinicians, and the availability of portable video laryngoscopes for use by clinicians for emergency airway management.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa
|
15-00602-425

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that pharmacy personnel conduct and document monthly medication storage area inspections and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Healthcare Inspection – Quality of Care Issues, Sheridan VA Healthcare System, Sheridan, Wyoming
|
14-00903-422

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the Facility Director ensure that staff comply with Veterans Health Administration and facility policies and practices related to the management of dysphagia, including assessment and documentation of a patient's response to the provided care recommendations and aspiration risk precautions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the Facility Director implement applicable recommendation(s) from previous event-related reviews, if any.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that the Facility Director review local privileging processes and ensures compliance with local policy and Veterans Health Administration Handbook 1100.19.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
|
15-00138-392

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that employees at the Haverhill CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Haverhill CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that the information technology server closet at the Haverhill CBOC is maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that testing of the panic alarm system is conducted at the Haverhill CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio
|
15-00595-417

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, that the committee document the screening reviews, and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility include Social Work Service, Chaplain Service, and the Rehabilitation Medicine and Service Care Line in the review of electronic health record quality.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that facility managers ensure that patient care areas are clean and in good repair and that areas under sinks are not used for storage and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that the recently implemented Consult Management Committee continue to meet regularly to review consult data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and includes all required elements and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that facility managers ensure the Domiciliary and Psychosocial Residential Rehabilitation Treatment Programs are clean and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the Domiciliary Residential Rehabilitation Treatment Program have a Class K fire extinguisher available in the kitchen used by residents.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility correct the deficiencies identified during monthly Domiciliary Residential Rehabilitation Treatment Program self-inspections and that documentation reflects correction.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that Domiciliary Residential Rehabilitation Treatment Program managers ensure residents secure medications in their rooms and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinicians ensure that the safety plans for all patients assessed to be at high risk for suicide specifically address suicidality and that facility managers monitor compliance.
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