Date Issued
|
Report Number
15-00875-129
All Reports
Date Issued
|
Report Number
14-04222-141
Open
Closed-Implemented
Closed-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.
Date Issued
|
Report Number
14-04473-132
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that the Facility Director ensure that documentation of procedure results from non-VA GI care providers is obtained and available in the electronic health record for review in a timely and consistent manner.
Date Issued
|
Report Number
13-01530-137
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/24/2015
We recommended the Interim Under Secretary for Health implement periodic training for non-VA medical care staff to ensure proper determination and use of payment and additional documentation criteria.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/11/2016
We recommended the Interim Under Secretary for Health modify Chief Business Office reviews to include a systematic review of emergency transportation claims.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/24/2015
We recommended the Interim Under Secretary for Health instruct the eight sampled VA medical facilities to initiate recovery of overpayments and reimbursement of underpayments identified in our audit.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 56,200,000.00
Date Issued
|
Report Number
14-00730-126
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended the Interim Under Secretary for Health establish oversight mechanisms to ensure Veterans Health Administration uses medical support and compliance funds in accordance with appropriation laws.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended the Interim Under Secretary for Health seek the return of all medical support and compliance funds used to develop and support the Health Care Claims Processing System.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended the Interim Under Secretary for Health deobligate all medical support and compliance funds that remain obligated toward the development of the Health Care Claims Processing System.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended the Interim Under Secretary for Health obtain the appropriate funding to support the development of the Health Care Claims Processing System, if additional system development requirements are unfunded.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/21/2016
We recommended the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to determine if appropriate administrative action should be taken against any senior officials in the Deputy Chief Business Office for Purchased Care's supervisory chain of command, and ensure that action is taken.
Date Issued
|
Report Number
14-00875-133
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that the Radiology Department uses software that is consistent with VA policy to schedule appointments.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers explore the use of the scheduling system by radiology clerks to ensure that appointments are reflected on patients’ appointment lists and that automated reminder letters and phone calls are generated or initiated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers develop and implement a scheduling policy and a formal training program for clerical staff to ensure consistency in scheduling practices.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/26/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers assess and monitor clerical needs to ensure all check-in areas are staffed, appointments are scheduled/rescheduled, and phones are answered or calls are returned timely.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers implement the facility’s plan for centralized radiology scheduling and procedures to ensure a timely response to phone calls or messages.
Date Issued
|
Report Number
14-03963-139
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/4/2015
We recommended the Under Secretary for Benefits adopt a permanent, universal policy for dates of claims that VA Regional Office staff should use to manage disability and benefits claims.
Date Issued
|
Report Number
14-04226-125
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the facility ensure that credentialing and privileging folders do not contain information that is not permitted.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and that the Chief of Staff attend meetings.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Morbidity and Mortality Conference review all surgical deaths with identified problems or opportunities for improvement.
No. 4
to Veterans Health Administration (VHA)
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. 5
to Veterans Health Administration (VHA)
We recommended that the facility designate a committee to oversee consult management.
No. 6
to Veterans Health Administration (VHA)
We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings date the forms upon review prior to the scan and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
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. 8
to Veterans Health Administration (VHA)
We recommended that the facility revise the stroke policy to address timeliness of completion and interpretation of computed tomography scans, timeframe for the availability of the stroke team, and the difference in approach to patients presenting within the facility’s defined timeframe and those presenting outside the defined timeframe and that the facility managers fully implement the revised policy.
No. 9
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that clinicians obtain and document signed informed consent and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
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. 14
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that critical care unit employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 15
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include that portable videolaryngoscopes be available at all times for use by clinicians.
No. 16
to Veterans Health Administration (VHA)
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Date Issued
|
Report Number
14-04229-130
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the Chief of Staff consistently attend meetings of the newly established Surgical Work Group.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the facility ensure service lines report electronic health record quality data to the Electronic Health Record Committee and that the committee analyze the data at least quarterly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that facility managers ensure patient care areas are clean and in good repair and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that facility managers ensure restrooms in the Emergency Department are clean and in good repair and monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that facility managers ensure the nurse call system alarms in the Emergency Department are audible and visual and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that facility managers ensure designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that Level 2 personnel document referral to a radiologist of patients identified as having applicable conditions during secondary screening and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
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 and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
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.
Date Issued
|
Report Number
14-02689-122
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations for temporary 100 percent disability evaluations.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 10/16/2015
We recommended the Boston VA Regional Office Director develop and implement a plan to review for accuracy the 189 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration’s second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing these claims to identify local training needs.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Boston VA Regional Office Director provide refresher training for staff on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 10/16/2015
We recommended the Boston VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director ensure Systematic Analyses of Operations are completed timely according to the annual schedule and that they contain thorough analyses, use appropriate data, and include recommendations with time frames for implementation.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Date Issued
|
Report Number
15-02101-143
Date Issued
|
Report Number
14-04476-116
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that managers ensure staff can access the
electronic version of safety data sheets at the Florence CBOC.
No. 2
to Veterans Health Administration (VHA)
We recommended that the information technology server closet
at the Florence CBOC is maintained according to information technology safety and
security standards.
No. 3
to Veterans Health Administration (VHA)
We recommended that the staff at the Florence CBOC receive
scheduled emergency management training.
No. 4
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. 5
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. 6
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. 7
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
14-04194-118
Date Issued
|
Report Number
14-03981-119
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 2/18/2015
We recommended the Oakland VA Regional Office Director complete the review of, and take appropriate action on, the remaining 537 informal claims and provide documentation to certify these actions are complete.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/18/2015
We recommended the Oakland VA Regional Office Director implement a plan to provide training to staff on proper procedures for processing informal claims and assess the effectiveness of that training.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/18/2015
We recommended the Oakland VA Regional Office Director implement a plan to ensure oversight of those staff assigned to process the informal claims.
Date Issued
|
Report Number
14-02022-134
Date Issued
|
Report Number
14-04386-124
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/22/2015
We recommended that the information technology server closet at the Polk Street VA Annex Clinic is maintained according to information technology safety and security standards.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/19/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/19/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/28/2017
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Date Issued
|
Report Number
14-04213-115
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility ensure that the Emergency Services Committee physician member consistently attends meetings and participates in code reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/11/2015
We recommended that the Safe Patient Handling Committee track patient handling injury data.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the Medical Record Committee include physician documentation in the review of electronic health record quality.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/21/2015
We recommended that the quality control policy for scanning include the quality of the source document, 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 readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/21/2015
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that facility managers ensure that medications
are secured at all times and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/12/2016
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. 9
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility ensure the high-alert/hazardous medication list is available for staff reference on the acute medicine unit and both community living center units.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that the facility ensure nursing staff review monthly inspections of nursing station medication areas.
Date Issued
|
Report Number
14-01708-123
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Facility Director ensure that senior leadership and nursing managers fully implement the VHA Nurse Staffing Methodology Plan as required.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/11/2015
We recommended that the Facility Director ensure that senior leadership and nursing managers fully evaluate the medical intensive care and step down units' patient mix, staffing plan, patterns of floating, physical layout, and unit assignments for opportunities for improvement and take necessary action.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/3/2015
We recommended that the Facility Director ensure that patient incident reporting processes be strengthened so that all patient incidents or safety concerns are reported promptly to the patient safety manager.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the Facility Director ensure that nursing staff perform and document fall risk assessments as required.