All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Tomah VA Medical Center, Tomah, Wisconsin
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14-04385-65

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Wausau CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that hand hygiene compliance is monitored at the Wausau CBOC and reported to the Infection Control Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that privacy is provided for veterans in the examination rooms at the Wausau CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2015
We recommended that the information technology server closet at the Wausau CBOC is maintained according to information technology safety and security standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that the staff at the Wausau CBOC receive regular information and updates on their responsibilities in emergency response operations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that the staff at the Wausau CBOC participate in scheduled emergency management training and exercises.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that RN Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2015
We recommended that clinic staff ensures that written patient educational materials provided to patients prior to or at the time of consent for HIV testing include all required elements.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Memphis VA Medical Center, Memphis, Tennessee
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14-04383-78

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees at the Savannah, TN, CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that safety inspections are performed on all the medical equipment at the Savannah, TN, CBOC in accordance with VA and Joint Commission standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hand hygiene compliance be monitored at the Savannah, TN, CBOC and reported to the Infection Control Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the Savannah, TN, CBOC to clearly identify all exits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Savannah, TN, CBOC and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Savannah, TN, CBOC to the parent facility.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that examination tables and curtains provide adequate privacy for women veterans at the Savannah, TN, CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Savannah, TN, CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that access to the information technology server closet at the Savannah, TN, CBOC is restricted and maintained according to information technology safety and security standards.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that access to the information technology server closet at the Savannah, TN, CBOC is documented consistently according to information technology safety and security standards.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York
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14-04210-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that the Medical Executive Committee and the Facility Director consistently review and approve revised privilege forms.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended that when conversions from observation bed status to acute admissions are 25–30 percent or more, the facility reassess observation criteria and utilization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the Critical Care 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 consistently collect code performance data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the Surgical Work Group meet monthly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility share patient handling injury data.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure patient care area floors and public restrooms are clean and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility repair damaged floors and wall surfaces in patient care areas.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that the facility repair damaged wheelchairs and furnishings in patient care areas or remove them from service.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that facility managers ensure all required members of the Environment of Care Committee consistently attend meetings 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 facility use special medication labeling and/or institute unique storage practices for the complete list of look-alike and sound-alike medications and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that facility managers ensure monthly medication storage area inspections are consistently completed and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that facility managers ensure that oral syringes are available for oral liquid medication administration and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility revise the local policy on inspection of medication storage areas to be consistent with Veterans Integrated Service Network policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that major bed services have designated Automated Data Processing Applications Coordinators.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2015
We recommended that facility managers post stroke guidelines on the three inpatient units and in the two community living centers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended that clinicians screen patients for difficulty swallowing, that screening be done prior to oral intake, and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended that the facility report to the Veterans Health Administration the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Healthcare Inspection – Alleged Quality of Care and Courtesy Issues at the Alamosa Community Based Outpatient Clinic, Alamosa, Colorado
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14-00615-61

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that the Facility Director implement the CBOC triage guidelines and train staff on the guidelines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that the Facility Director ensure that managers appropriately address CBOC staff who exhibit lapses in competency, when identified.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Gulf Coast Veterans Health Care System, Biloxi, Mississippi
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14-04380-79

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that employees at the Mobile Outpatient Clinic CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
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: 3/30/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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: 3/30/2016
We recommended that licensed Providers in the outpatient clinics receive health coaching 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: 7/13/2015
We recommended that the Facility Director identifies a Lead Human Immunodeficiency Virus Clinician to carry out required responsibilities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that clinic staff ensures that written patient educational materials are provided to patients prior to or at the time of consent for human immunodeficiency virus testing and include all required elements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2017
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2017
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Samuel S. Stratton VA Medical Center, Albany, New York
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14-04368-56

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2015
We recommended that the information technology server closet at the Polk Street VA Annex Clinic is maintained according to information technology safety and security standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2016
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: 1/19/2016
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: 4/28/2017
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching 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: 3/24/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania
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14-02073-57

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that the Surgical Work Group meet monthly and review relevant data elements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that processes be strengthened to ensure that the Transfusion Review Committee members from Medicine, Surgery, and Anesthesia Services consistently attend meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that the facility¿s stroke policy/plan/guideline be revised to address screening for difficulty swallowing, that the policy/plan/guideline be fully implemented, and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2015
We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that processes be strengthened to ensure that fire emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients¿ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that barriers are properly used to restrict access to magnetic resonance imaging Zone III and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that magnetic resonance imaging technologists have visual contact at all times with patients in the magnet room.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that processes be strengthened to ensure that the two-way communication device is regularly tested and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2015
We recommended that a Magnetic Resonance Imaging Safety Committee be appointed.
Healthcare Inspection – Quality of Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida
|
14-02887-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2015
We recommended that the Facility Director ensure that patient safety incidents and concerns are reported promptly to the patient safety manager and that the need for further review and/or corrective actions is assessed initially by the patient safety manager.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2015
We recommended that the Facility Director ensure that cardiac resuscitation events in the operating room are appropriately documented and reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that the Facility Director ensure that the Critical Incident Tracking Notification system recipient list includes the patient safety manager.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Facility Director assess staffing in the Quality Management Service and take appropriate actions to meet the workload requirements.
Review of Alleged Mismanagement at VHA’s Massachusetts Veterans Epidemiology Research and Information Center
|
14-00517-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, improve oversight controls to ensure Massachusetts Veterans Epidemiology Research and Information Center staff protects all veteran personal information in accordance with VA policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, ensure that portable storage devices used by the Massachusetts Veterans Epidemiology Research and Information Center are encrypted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, ensure VA Boston Healthcare System Information Security Officers have full access to all VA Boston Healthcare System office space, including all Massachusetts Veterans Epidemiology Research and Information Center office space, in order to perform their oversight responsibilities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2015
We recommended the Director of Veterans Integrated Service Network 1 develop an oversight and monitoring plan to ensure Massachusetts Veterans Epidemiology Research and Information Center staff comply with VA’s information security requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended the Director of Veterans Integrated Service Network 1 implement a plan to maximize use of the off-site commercial space if continued need for the office space is justified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 593,000.00
Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet
|
14-04705-62

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that the Interim Under Secretary for Health conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 11/13/2015
We recommended that the Interim Under Secretary for Health ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 11/13/2015
We recommended that after reviewing the circumstances of any inappropriate resolution of consults, the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
Healthcare Inspection – Follow-Up Evaluation of Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn, VA Medical Center, Columbia, SC
|
13-00872-52

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended that the Facility Director ensure that patient information, medical and surgical supplies, medications, grafts, and patches are stored properly throughout the facility and that compliance be monitored to ensure sustained improvement.
Healthcare Inspection – Alleged Inappropriate Opioid Prescribing Practices, Chillicothe VA Medical Center, Chillicothe, OH
|
14-00351-53

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Facility Director identify patients receiving recurrent prescriptions for high potency and/or large quantity opioid medications and ensure appropriate periodic assessments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Facility Director ensure that prescribing physicians check the Ohio Automated Rx Reporting System for patients who are prescribed high potency and/or large quantity opioid medications.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Central Alabama Veterans Health Care System, Montgomery, Alabama
|
14-00930-14

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Dothan and Wiregrass CBOCs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that managers ensure that material safety data sheets are readily available to staff at the Wiregrass CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Dothan CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that processes are improved to ensure the tracking of chemical inventories at the Dothan CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that the effectiveness of the panic alarm system is evaluated at the Wiregrass CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that panic alarms are tested and testing is documented at the Dothan and Wiregrass CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that no clean items are stored in the medical (infectious) waste storage room at the Wiregrass CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that signage is installed to identify the medical (infectious) waste storage room at the Wiregrass CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2015
We recommended that computer screens are secured to eliminate viewing of personally identifiable information by unauthorized individuals at the Wiregrass CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that processes are improved to ensure the use of privacy screens on computers in high-traffic areas at the Wiregrass CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that the parent facility maintain evidence of the contractor’s compliance with facility required education, training, planning, and participation in annual disaster exercises for the Dothan and Wiregrass CBOCs.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that the parent facility’s Emergency Management Committee evaluate the Dothan and Wiregrass CBOCs’ emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2017
We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2015
We recommended that staff provide medication counseling/education as required.
Audit of VHA's National Call Center for Homeless Veterans
|
13-01859-42

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended the Interim Under Secretary for Health end the use of the answering machine and improve the utilization and accessibility of the National Call Center for Homeless Veterans current counselors before consideration is given to hiring additional staff.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health implement effective performance measures and benchmarks for the National Call Center for Homeless Veterans and performance standards for staff to ensure the accessibility of counselors, the efficient management of calls, and the proper referral of veterans' calls.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended the Interim Under Secretary for Health routinely monitor and analyze National Call Center for Homeless Veterans telephone system data to assess the quality of Call Center support services, including the counselors' accessibility, efficiency in answering calls, and issuance of referrals.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health ensure that Call Center officials adhere to Veterans Health Administration's National Call Center for Homeless Veterans policy requirements related to monitoring referred calls.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended the Interim Under Secretary for Health implement management controls to ensure VA medical facilities receive feedback on the quality of their referral responses and on needed corrections and improvements to the homeless support services extended to referred veterans.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health review the results of this audit with the VA medical facilities' homeless points of contact to ensure they understand their responsibility to ensure referred veterans receive needed support services.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health implement controls to ensure National Call Center for Homeless Veterans special purpose funds are used as intended.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 267,000.00
An Analysis of Mental Health, Primary Care, and Specialty Care Productivity and Related Issues, El Paso VA Health Care System, El Paso, Texas
|
14-05128-51

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended that the Facility Director review clinic productivity and implement a plan to enhance productivity in those clinics for which productivity is an issue.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director ensure clinical departments accurately capture provider workload.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director direct clinical departments to review labor mapping to ensure the labor mapping is up to date and accurately reflects the percentage of provider time allocated to direct patient care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director review the quadrants into which mental health, primary care, and specialty care clinics appear on the VHA Specialty Productivity-Access Report and Quadrant (SPARQ) tool, and evaluate and address underlying factors.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director take measures to promote alignment of organizational structure with clinic centered accountability, goals, and expectations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director revise policy and/or processes to facilitate primary care Patient Aligned Care Team (PACT) operation and support PACT model workflow and clinic-wide coordination of care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director identify specialties particularly vulnerable to loss of a provider and explore contingency plans to potentially mitigate the impact of provider loss on clinic disruption.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director take measures to promote non-provider to provider communication within mental health, primary care, and specialty clinics.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director consider inter-service agreements between primary care and specialty care clinics.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director direct MH clinic leadership to evaluate access and patient engagement for specific types of outpatient mental health services, including individual psychotherapy and intensive substance use treatment, in order to provide a more encompassing picture of MH access.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director provide a quarterly update on facility efforts to revise outpatient MH clinic processes to promote greater continuity of care through the regular outpatient MH clinic and to better focus the walk-in clinic toward serving those in need of walk-in care.
Combined Assessment Program Review of the VA Northern California Health Care System, Mather, California
|
14-02081-41

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that the Surgical Work Group meet monthly, include the Chief of Staff as a standing member, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed at least quarterly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that the Medical Records Committee meet quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Function Team meeting minutes document those actions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that processes be strengthened to ensure that rolling equipment and patient weight scales are cleaned on a routine basis and that damaged furniture in patient care areas is repaired or removed from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the eye clinic waiting room carpet be replaced to avoid tripping hazards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the facility's stroke policy be revised to address screening patients for difficulty swallowing and the difference in approach to patients presenting within and after 2 hours of onset of symptoms, that the policy be fully implemented, and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the facility collect and report to the Provision of Care Committee the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that processes be strengthened to ensure that clinicians obtain a partial thromboplastin time test while assessing patients presenting with stroke symptoms and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommend that that processes be strengthened to ensure that initial patient safety screenings are conducted and documented in the electronic health records and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommend that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that facility policy be revised to fully meet VHA requirements and that processes be strengthened to ensure that quarterly Magnetic Resonance Imaging Safety Committee meetings are held and biannual magnetic resonance imaging safety inspections are conducted and that compliance be monitored.
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas
|
14-02080-29

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff document monthly restorative nursing services progress notes in residents’ electronic health records and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that residents are offered transfer from their wheelchairs to regular dining chairs during meal periods.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health record.
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