All Reports

Healthcare Inspection – Patient Telemetry Monitoring Concerns, Michael E. DeBakey VA Medical Center, Houston, Texas
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14-03927-197

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that the Facility Director ensure that the appropriateness of assigning patients to telemetry is reviewed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that the Facility Director ensure dedicated wireless telephones are continuously carried by unit charge nurses or designees for effective communication between unit and telemetry monitoring technicians as required by local policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Martinsburg VA Medical Center, Martinsburg, West Virginia
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15-00108-194

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fort Detrick CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that employees at the Fort Detrick CBOC receive the required training on hazardous materials.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that personal protective equipment is available for all staff at the Fort Detrick CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that staff protect patient-identifiable information on laboratory specimens at the Fort Detrick CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that the information technology server closet at the Fort Detrick CBOC is maintained according to information technology safety and security standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within the time frame specified in VHA policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2016
We recommended that all providers and clinical associates in the outpatient clinics receive health coaching training within the time frame specified in VHA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Healthcare Inspection – Suicide Risk and Alleged Medical Management Issues, Hampton VA Medical Center, Hampton, Virginia
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14-02139-156

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that contracted providers in all patient care areas complete the Veterans Health Administration’s suicide risk management training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure development of a process to measure the effectiveness of Veterans Health Administration required suicide risk management training for all staff members who have completed it and to provide remedial training when needed.
Combined Assessment Program - Evaluation of Coordination of Care in Veterans Health Administration Facilities
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15-01809-163

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians provide and document discharge instructions for all identified needs and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reassess patients¿ learning needs prior to providing important instructions, including discharge instructions, and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians reconcile conflicting needs and instructions before discharging patients and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that patients receive ordered post-discharge referrals and that facility managers monitor compliance.
Audit of VA's Drug-Free Workplace Program
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14-02383-175

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/8/2016
We recommended the Deputy Assistant Secretary for Human Resources Management ensure that all final selectees for Testing Designated Positions complete pre-employment drug testing prior to appointment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/8/2016
We recommended the Deputy Assistant Secretary for Human Resources Management collect data that would ensure accountability that all employees selected for random drug testing are tested.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/9/2017
We recommended the Deputy Assistant Secretary for Human Resources Management develop procedures to ensure the Drug Testing coding of employees in Testing Designated Positions is accurate and complete in the Personnel and Accounting Integrated Data system.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/25/2016
We recommended the Deputy Assistant Secretary for Human Resources Management coordinate with the Under Secretary for Health to implement procedures to ensure Custody and Control forms are accurately completed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/8/2016
We recommended the Deputy Assistant Secretary for Human Resources Management implement processes to adequately monitor local compliance with VA's Drug-Free Workplace Program requirements.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Dayton VA Medical Center, Dayton, Ohio
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15-00116-191

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Lima CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Lima CBOC and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that processes are strengthened at the Lima CBOC to ensure that women veterans can access gender-specific restrooms without entering public areas at the Lima CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Inspection of VA Regional Office Manchester, New Hampshire
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14-04623-120

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/28/2015
We recommended the Manchester VA Regional Office Director conduct a review of the 111 temporary 100 percent disability evaluations remaining from their inspection universe as of August 21, 2014, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/28/2015
We recommended the Manchester VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/28/2015
We recommended the Manchester VA Regional Office Director enforce Veterans Benefits Administration's second-signature review policy for traumatic brain injury rating decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/28/2015
We recommended the Manchester VA Regional Office Director enforce the VARO's second signature review policy for special monthly compensation and ancillary benefits rating decisions.
Inspection of VA Regional Office Fargo, North Dakota
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14-04622-150

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2015
We recommended the Fargo VA Regional Office Director provide training and assess the effectiveness of that training, to ensure staff properly establish permanent disability evaluations when required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/10/2015
We recommended the Fargo VA Regional Office Director conduct a review of the 40 temporary 100 percent disability evaluations remaining from their universe as of August 21, 2014, and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/10/2015
We recommended the Fargo VA Regional Office Director implement a plan to ensure staff address all pending issues related to SMC and ancillary benefits.
Review of Alleged Data Manipulation at VA Regional Office Honolulu, HI
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15-00880-157

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2015
We recommended the Honolulu VA Regional Office Director take immediate action to fully review and correct, as appropriate, all improper actions taken by the supervisor.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2015
We recommended the Honolulu VA Regional Office Director ensure staff receive training on the proper procedures for processing dependency questionnaires.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2015
We recommended the Honolulu VA Regional Office Director confer with Regional Counsel and human resources to determine the appropriate administrative action to take, if any, against this employee.
Administrative Investigation, Prohibited Personnel Practice and Misuse of VA Time and Resources, Veterans Health Administration, Chief Business Office Purchased Care, Denver, CO
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14-00730-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommend that the Acting 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 corrective action to take, if any, concerning the prohibited personnel practice and improper use of a non-competitive hiring authority to reinstate Mr. Sigley.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommend that the Acting Principal Deputy Under Secretary for Health (PDUSH) confer with OHR and OGC to determine the appropriate administrative action to take, if any, against (redacted).
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2015
We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against (redacted).
Healthcare Inspection - Delay of Care, Goshen Community Based Outpatient Clinic, Goshen, Indiana
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15-00794-151

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended that the VA Northern Indiana Health Care System Director ensure a review of this patient's care is conducted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended that the VA Northern Indiana Health Care System Director ensure Goshen Community Based Outpatient Clinic patients are aware of the process for contacting a VA Northern Indiana Health Care System Patient Advocate when concerns regarding provider communication or access to medical care arise.
Healthcare Inspection – Staffing and Quality of Care Issues in the Community Living Center, Charlie Norwood VA Medical Center, Augusta, Georgia
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14-02437-117

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that the Facility Director require that all nursing staff in the Community Living Center receive the required training on the use of the wound vacuum assisted closure device.
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