All Reports
Date Issued
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Report Number
14-00463-172
Date Issued
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Report Number
14-04437-178
Date Issued
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Report Number
14-01308-171
Date Issued
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Report Number
12-03487-174
Date Issued
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Report Number
14-01088-165
Date Issued
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Report Number
13-03948-169
Date Issued
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Report Number
13-03411-167
Date Issued
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Report Number
13-03176-168
Date Issued
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Report Number
14-04394-145
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 2
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
to Veterans Health Administration (VHA)
We recommended that providers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
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.
No. 6
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
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Report Number
14-04227-147
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that the Procedure and Anesthesia Care Council include the Chief of Staff and Surgical Quality Nurse as members.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the facility analyze electronic health record quality data at least quarterly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the quality control policy for scanning include the quality of the source document and alternative means of capturing data when the quality of the source document does not meet image quality controls.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that the facility implement actions to address all high-risk areas and follow up on those actions and ensure Infection and Environmental Control Committee meeting minutes document this.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that facility managers ensure all designated critical care employees receive annual bloodborne pathogens training and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that the facility consistently 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
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility educate employees that intravenous syringes are not to be used to measure oral liquid medications and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure that multi-dose injector pens are not stored as ward stock in patient care areas and that they contain patient specific labels and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility complete secondary patient safety screenings for all patients immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
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. 14
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the facility ensure appropriate barriers are in place to restrict unauthorized or accidental access to magnetic resonance imaging Zone IV.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians obtain and document informed consent for tissue plasminogen activator and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers post stroke guidelines in all areas where patients may present with stroke symptoms.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that facility managers provide a stroke education program for employees involved in assessing and treating stroke patients and that facility managers monitor compliance.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
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. 23
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that Radiology Service revise its policy to clearly define the required on-call reporting time for computed tomography scan and magnetic resonance imaging and the on-call response time for radiology interpretation.
Date Issued
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Report Number
12-03002-102
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/18/2015
We recommend that the Deputy Under Secretary for Health for Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Project Manager.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/18/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against Mr. Hoffman, Ms. Goolsby, Mr. Galkowski, and Ms. Kaplan.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommend that the DUSHOM ensure Mr. Hoffman, Ms. Goolsby, Mr. Galkowski, Ms. Kaplan, and the Project Manager take refresher ethics training directly related to the matters described in this report.
No. 4
to General Counsel (OGC)
Closure Date: 2/25/2016
We recommend that OGC review this entire matter from start to end, to include but not limited to, the solicitation of interested property owners, the MST evaluation of properties, property ownership and purchase, and the Project Manager being the project manager with oversight of the construction of the leased healthcare center and determine the appropriate corrective action, if any, to take.
Date Issued
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Report Number
13-00716-101
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health implement mechanisms that effectively identify demand for Non-Institutional Care services to ensure that veterans who need these services are provided the opportunity to participate in the Home Telehealth Program.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health develop specific performance measures to promote enrollment of Non-Institutional Care patients into the Home Telehealth Program.
Date Issued
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Report Number
15-00190-146
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director ensure that clinicians involve patients in the treatment planning process and discuss any proposed changes to treatment plans with patients.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended that the Facility Director ensure that patients receive education on their medical conditions and that education is documented in the electronic health record.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director evaluate the VA care provided to the patient summarized in this report and confer with Regional Counsel regarding the need for possible disclosure.
Date Issued
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Report Number
15-00874-131
Date Issued
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Report Number
15-00875-129
Date Issued
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Report Number
14-04222-141
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers review privilege forms annually and document the review.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that facility managers ensure that privileges granted are appropriate for the practitioners’ skills and training.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
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. 4
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the Acute Care Advisory Board 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. 5
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the facility keep the recipient list for the automated e-mail notification current
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the facility analyze electronic health record data at least quarterly and include most services in the review of electronic health record quality.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that the facility implement a process for the destruction of original documents.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the Safe Patient Handling Committee report patient handling injury data quarterly.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility designate Automated Data Processing Applications Coordinators to train employees and to manage, implement, and maintain the computerized consult package.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that the facility conduct cardiac arrest, contrast reaction, and fire emergency drills in magnetic resonance imaging and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that Level 2 magnetic resonance imaging personnel and/or radiologists 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. 13
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that facility employees regularly test the two-way communication device and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility update local magnetic resonance imaging policies for policy changes and review the policies at least every 3 years and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the facility revise the stroke policy to include clinical protocols or pathways, timeliness of completion and interpretation of computed tomography scans, emergent transfer to the nearest primary stroke center, the difference in approach to patients presenting within the facility’s defined timeframe for tissue plasminogen activator and those presenting outside of that timeframe, and screening for difficulty swallowing prior to oral intake and that facility managers fully implement the revised policy.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that facility managers post stroke guidelines in the Emergency Department and community living center and on all inpatient units.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that facility managers provide a stroke education program for employees who assess and treat stroke patients.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that domiciliary employees conduct and document monthly domiciliary self-inspections that include all required elements, submit work orders for items needing repair, and ensure correction of any identified deficiencies and that domiciliary managers monitor compliance.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that domiciliary employees perform and document contraband inspections, rounds of all public spaces, and inspections for unsecured medications and that domiciliary managers monitor compliance.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommend that the domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers ensure that closed circuit television with recording capabilities is installed in all domiciliary public areas.
No. 26
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
No. 27
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 28
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility managers monitor compliance.
No. 29
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements and that facility managers monitor compliance.
No. 30
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
No. 31
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 32
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure that all Emergency Department clinicians and clinicians with moderate sedation privileges have emergency airway management privileges.
No. 33
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that facility managers strengthen processes to minimize a repeat occurrence in which non-privileged providers perform intubations and in instances of occurrence, initiate root cause analyses.
No. 34
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that facility managers ensure quarterly reporting of emergency airway management data to the designated committee.
No. 35
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that facility managers ensure reporting of results of completed Focused Professional Practice Evaluations for all newly hired licensed independent practitioners to the Medical Executive Committee.
No. 36
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that facility managers ensure the Medical Records Committee monitors the copy and paste functions.
No. 37
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that facility managers ensure patient notification of positive colorectal cancer screening test results within the required timeframe and that clinicians document notification.
No. 38
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that facility managers ensure responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
No. 39
to Veterans Health Administration (VHA)
Closure Date: 6/19/2017
We recommended that facility managers ensure patient notification of diagnostic test results within the required timeframe and that clinicians document notification.
Date Issued
|
Report Number
14-04396-142
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Worcester CBOC to the parent facility.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that the information technology server closet at the Worcester CBOC is maintained according to information technology safety and security standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/31/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
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. 6
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
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.
Date Issued
|
Report Number
14-04228-144
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that facility managers review privilege forms
annually and document the review.
No. 2
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
No. 3
to Veterans Health Administration (VHA)
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
to Veterans Health Administration (VHA)
We recommended that the quality control policy/process for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 5
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee minutes reflect sufficient detail regarding corrective actions for identified deficiencies and track corrective actions to closure.
No. 6
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged floors and walls in patient care areas.
No. 7
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace damaged furnishings, plumbing fixtures, and windows in patient care areas.
No. 8
to Veterans Health Administration (VHA)
We recommended that all required Environment of Care Committee members consistently attend committee meetings and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that the facility conduct and document annual complete system checks of the community living center’s elopement prevention system and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users.
No. 11
to Veterans Health Administration (VHA)
We recommended that Mental Health Service’s Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.