Date Issued
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Report Number
14-01422-180
All Reports
Date Issued
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Report Number
13-03862-182
Date Issued
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Report Number
13-01877-173
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
|
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
|
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
|
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
|
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
|
Report Number
15-00874-131