All Reports

Combined Assessment Program Review of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
|
14-04228-144

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged floors and walls in patient care areas.
No. 7
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection — Alleged Mismanagement of Gastroenterology Services and Quality of Care Deficiencies, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
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14-04473-132

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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.
Audit of Non-VA Medical Care Claims for Emergency Transportation
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13-01530-137

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Review of Alleged Misuse of VA Funds to Develop the Health Care Claims Processing System
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14-00730-126

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection — Radiology Scheduling and Other Administrative Issues, Phoenix VA Health Care System, Phoenix, Arizona
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14-00875-133

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Alleged Data Manipulation at the VA Regional Office Little Rock, Arkansas
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14-03963-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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14-04226-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and that the Chief of Staff attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility designate a committee to oversee consult management.
No. 6
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians obtain and document signed informed consent and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Beckley VA Medical Center, Beckley, West Virginia
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14-04229-130

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Inspection of the VA Regional Office Boston, Massachusetts
|
14-02689-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Cincinnati VA Medical Center, Cincinnati, Ohio
|
14-04476-116

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Florence CBOC receive scheduled emergency management training.
No. 4
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. 5
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. 6
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.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Alleged Mismanagement of Informal Claims Processing at VA Regional Office Oakland, California
|
14-03981-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA North Texas Health Care System, Dallas, Texas
|
14-04386-124

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Tomah VA Medical Center, Tomah, Wisconsin
|
14-04213-115

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Staffing and Patient Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida
|
14-01708-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Erie VA Medical Center, Erie, Pennsylvania
|
14-04389-106

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
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.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers develop and communicate an egress plan for the safety of all patients.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes are strengthened to ensure that women veterans can access gender-specific restrooms without entering public areas.
No. 4
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
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. 7
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. 8
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 Erie VA Medical Center, Erie, Pennsylvania
|
14-04224-107

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that facility managers monitor the recently revised reprivileging process to ensure practitioners have the appropriate skills and training for emergency airway management.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2015
We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2015
We recommended that Medicine Service designate an Automated Data Processing Applications Coordinator.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
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