All Reports

Healthcare Inspection – Quality of Care and Access to Care Concerns, Jack C. Montgomery VA Medical Center, Muskogee, OK
|
14-04573-378

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director evaluate the care of the cases discussed in this report with Regional Counsel for possible disclosure(s) to the patient(s) and/or surviving family members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director require the Facility Director to conduct peer reviews of the cases identified in this report and take appropriate action to evaluate clinical competence of the providers involved in these cases based on the results of those reviews and this report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director send a team to evaluate the facility’s Dental Service and oversee the implementation of any recommendations for improvement in scheduling and the general provision of dental care at the facility made by that team.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director provide appropriate and timely neurosurgical consultation services to patients receiving care at the facility consistent with Veterans Health Administration Directive 2008-056, VHA Consult Policy, September 16, 2008.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that all documents that patients and non-VA providers receive regarding maternity/obstetric care and services are reviewed and revised to eliminate ambiguous language.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that providers document all clinically pertinent telephone conversations concerning patient care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Veterans Integrated Service Network and the Facility Director ensure adequate parking space requirements to strengthen a safe work environment, patient satisfaction, and provide optimal safety to patients, visitors, and staff.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network and the Facility Director ensure that Ernest Childers VA Outpatient Clinic access and parking is adequate and safe for patients, visitors, and employees.
Combined Assessment Program Summary Report - Evaluation of Medication Oversight and Education in Veterans Health Administration Facilities
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15-00359-374

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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 Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians adjust fluoroquinolone doses and/or frequencies consistent with manufacturers' recommendations when patients' estimated glomerular filtration rate values are below targeted thresholds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians providing medication education document the accommodations made to address patients¿ identified learning barriers.
Review of Second Instance of Employee Data Manipulation at the Houston VA Regional Office
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15-02354-220

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear or cancel controls for claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director implement a plan to routinely monitor system controls for pending claims, to prevent further manipulation attempts and ensure staff do not prematurely change or remove controls.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director submit the 13 remaining and previously unavailable claims the employee cancelled in FY 2013 to OIG for review.
Healthcare Inspection – Medication Management Concerns, South Texas Veterans Health Care System, San Antonio, Texas
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15-00425-380

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the System Director ensure that processes be developed to improve storage conditions of compounded sterile products on applicable patient units in an effort to reduce unnecessary waste.
Healthcare Inspection – Alleged Magnetic Resonance Imaging Order Deletion and Record Destruction, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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14-02195-381

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that the Facility Director ensure that Radiology Department managers confirm that ordered magnetic resonance imaging exams are scheduled and completed within the Veterans Health Administration required timeframe.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that the Facility Director require Radiology Department managers to review pending lists of magnetic resonance imaging exams at designated intervals to ensure timely scheduling of these exams and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that the Facility Director ensure Radiology Department managers develop and implement a consistent procedure for canceling magnetic resonance imaging orders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the Facility Director ensure that responsible providers are notified of canceled magnetic resonance imaging orders.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/20/2015
We recommended that the Facility Director ensure that radiology clerical staff accurately annotate reasons for canceling magnetic resonance imaging orders and appointments in the electronic health record.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of North Florida/South Georgia Veterans Health System, Gainesville, Florida
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15-00143-372

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
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: 1/13/2016
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
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: 1/13/2016
We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coach 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: 11/30/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians consistently notify patients of their laboratory results within 14 days, per local and VHA policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Chillicothe VA Medical Center, Chillicothe, Ohio
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15-00131-373

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that signage is installed at the Marietta CBOC to clearly identify the location of fire extinguishers obscured from view.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that the information technology server closet at the Marietta CBOC is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Clinic Registered Nurse Managers receive motivational interviewing and health coaching training within the time frame specified by VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that providers in the outpatient clinics receive health coaching training within the timeframe specified by VHA policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
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: 12/21/2015
We recommended that clinicians consistently notify patients of their lab results within 14 days as required by VHA.
Healthcare Inspection – Alleged Poor Mental Health Care Resulting in a Patient Death, VA Central Iowa Health Care System, Des Moines, Iowa
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15-02627-386

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommended that the Interim Under Secretary for Health determine the feasibility and advisability of expanding recovery coordination activities to patients with post-traumatic stress disorder.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that the Veterans Integrated Service Network Director ensure that the VA Central Iowa Health Care System Director provides all levels of Operation Enduring Freedom/Operation Iraqi Freedom case management services in accordance with Veterans Health Administration policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
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15-00125-367

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Phoenix VA Health Care System, Phoenix, Arizona
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15-00128-359

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Southeast VA CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hand hygiene compliance is monitored at the Southeast VA CBOC and reported to the Infection Control Committee.
No. 3
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 Southeast VA CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closets at the Southeast VA CBOC are maintained according to information technology safety and security standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Southeast VA CBOC participate in scheduled emergency management training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 9
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. 10
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona
|
14-04220-363

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the Surgical Work Group include the Chief of Staff as a member.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended 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 facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2017
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians obtain cardiac markers, partial thromboplastin time, and an electrocardiogram while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
We recommended that facility managers ensure that medicine/telemetry unit employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Sierra Nevada Health Care System, Reno, Nevada
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15-00127-357

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that panic alarms are tested and testing is documented at the Reno East Campus CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
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: 1/6/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Healthcare Inspection - Review of Solo Physicians’ Professional Practice Evaluations in Veterans Health Administration Facilities
|
15-00911-362

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended that the Interim Under Secretary for Health ensure that gastroenterology, pathology, nuclear medicine, and radiation oncology program offices define specialty specific criteria or monitors for use in Focused and Ongoing Professional Practice Evaluations and require consistent application across the Veterans Health Administration and that program offices monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended that the Interim Under Secretary for Health require a process to obtain input for evaluating professional practice from another physician in the same specialty when a physician is the only one of any specialty at a facility and require each Veterans Integrated Service Network to monitor compliance.
Combined Assessment Program Review of the VA Boston Healthcare System, Boston, Massachusetts
|
15-00078-364

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
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: 11/25/2015
We recommended that the facility develop a plan to complete the conversion from a six-part credentialing and privileging folder to a two-part privileging folder.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that the facility repair damaged floors, ceilings, and walls in patient care areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that facility managers ensure all patient care areas are clean and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that facility managers ensure that all furnishings on the acute behavioral health unit comply with the standards of the VA Mental Health Environment of Care Checklist and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that the facility repair damaged or worn furnishings in patient care areas or remove them from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that facility managers ensure all designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended that the facility revise the stroke policy to require the stroke team to respond in person within 30 minutes of receiving a call and that facility managers fully implement the revised policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that facility managers ensure that A2 and 3N nurses have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada
|
15-00079-358

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the Intensive Care Unit Committee review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the Environment of Care Committee share patient handling injury data with the newly designated safe patient handling coordinator/champion.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility establish a committee to provide oversight and coordination of electronic health record quality review activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure patient care equipment items and surfaces are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure all designated critical care employees receive annual bloodborne pathogens training and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure walk-off sticky mats are changed as needed to minimize dust and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that facility managers ensure that the temporary construction barrier is equipped with a self-closing door with a metal frame for worker access.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2016
We recommended that the facility educate employees on the medical and community living center units that intravenous syringes are not to be used to measure oral liquid medications and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility implement an acute ischemic stroke policy that addresses all required items.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers post stroke guidelines in all required patient care areas.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that the facility ensure that a qualified physician is present in the Emergency Department at all times, that non-Emergency Department clinicians are assigned inpatient emergency airway management coverage from 9:00 p.m. to 7:00 a.m., and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility ensure patients with positive colorectal cancer screening test results receive diagnostic testing within the required timeframe and that facility managers monitor compliance.
Audit of Fiduciary Program’s Management of Field Examinations
|
14-01883-371

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/25/2018
We recommended the Under Secretary for Benefits implement a plan to ensure field examination workload is completed in compliance with timeliness standards.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 4/4/2018
We recommended the Under Secretary for Benefits use the percentage of untimely field examinations in addition to the average days pending performance measure to better evaluate completion of field examinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/20/2017
We recommended the Under Secretary for Benefits require hub managers to use Beneficiary and Fiduciary Field System reports to identify and correct unscheduled field examinations at least once per quarter.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/20/2015
We recommended the Under Secretary for Benefits implement a plan to ensure the Beneficiary and Fiduciary Field System’s functionality is enhanced to require a date for scheduled field examinations be entered before exiting the system.
Administrative Investigation, Misuse of Position and Failure to Disclose and to Satisfy Financial Obligations, Veterans Benefits Administration, VA Regional Office, Philadelphia, PA
|
14-04494-347

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommend that the Eastern Area Director confer with the Offices of General Counsel (OGC) and Human Resources (OHR) to take appropriate administrative action, if any, against Ms. Filipov.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommend that the Eastern Area Director confer with OGC and OHR to ensure that Ms. Filipov receives refresher ethics training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommend that the Eastern Area Director confer with the Offices of General Counsel (OGC) and Human Resources (OHR) to take appropriate administrative action, if any, against Mr. Hodge.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommend that the Eastern Area Director confer with OGC and OHR to ensure that Mr. Hodges receives refresher ethics training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommend that the Eastern Area Director confer with OGC to ensure Mr. Hodge's Confidential Financial Disclosure Reports for past years are reviewed and any necessary action is taken as a result of that review.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Beckley VA Medical Center, Beckley, West Virginia
|
14-04398-340

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Greenbrier County CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that written procedures are available and staff are trained to properly disinfect non-critical medical equipment as required at the Greenbrier County CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Greenbrier County CBOC is maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Greenbrier County CBOC receive regular information/updates on their responsibilities in emergency response operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Greenbrier County CBOC participate in scheduled emergency management training and exercises.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 8
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. 9
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Healthcare Inspection – Administrative and Quality of Care Concerns, Martinsburg VA Medical Center, Martinsburg, West Virginia
|
13-04212-346

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the Facility Director ensure that the facility comply with Veterans Health Administration’s and facility test results notification requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the Facility Director ensure that the facility strengthen the root cause analysis process.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that the Facility Director ensure that the facility evaluate the care of the subject patient with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the Facility Director ensure that the facility strengthen and monitor the peer review process.
Combined Assessment Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
|
15-00077-352

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
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: 11/19/2015
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: 11/19/2015
We recommended that the Surgical Work Group document its review of National Surgical Office reports and surgery performance improvement activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that the 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: 6/17/2016
We recommended that the Medical Executive Board analyze reports of electronic health record quality review results at least quarterly and include most services in the review of electronic health record quality.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that facility managersensure Emergency Department/urgent care center monthly medication storage area inspections are completed and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility revisethe policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that requestorsconsistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians complete National Institutes of Health stroke scales for each stroke patient within the expected timeframe and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that facility managers post stroke guidelines on the medical intensive care unit/cardiac care unit, the surgical intensive care unit, 2 West - medicine/surgery, 4 West - medicine/surgery, and the progressive care unit.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility collect and 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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that Radiology Service revise the computed tomography scan on-call policy to require a 30-minute reporting time.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
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 before placement on the out of operating room airway management coverage list and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the Facility Director ensure designated clinicians have properly completed and granted privileges or scopes of practice.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility ensure that subordinate committees report data to the appropriate oversight committee and that the oversight committee reviews and analyzes data, takes appropriate action, and tracks actions to completion.
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