All Reports

Healthcare Inspection – Lapses in Access and Quality of Care, VA Maryland Health Care System, Baltimore, Maryland
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14-03824-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the System Director ensure that patient aligned care team provider staffing is adequate to provide patients with timely access to care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the System Director ensure that a contingency plan for patient aligned care team provider shortages is developed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the System Director ensure that patient aligned care team cancellations and other data are monitored to determine when there is a need to activate a contingency plan.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the System Director ensure that staff comply with local and national policies on contacting patients when scheduling mental health services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the System Director ensure that policy requirements for discontinuation of mental health consultation are clear and that staff comply with those requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2017
We recommended that the System Director ensure that the Access Action Plan for Orthopedic Surgery Services is carried out in an effort to improve access to orthopedic surgical services.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the System Director ensure that providers comply with their responsibilities of electronic health record documentation of the community care of co-managed patients.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2016
We recommended that the System Director ensure compliance with local policy requiring that community health care records be scanned into the electronic health records of co-managed patients.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that the System Director ensure that the local outpatient tube-feeding policy and practice comply with Veterans Health Administration requirements.
Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX
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13-01730-159

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/16/2016
We recommend that the VA Chief of Staff (COS) confer with the Offices of Human Resources (OHR), General Counsel (OGC), and Accountability Review (OAR) to determine the appropriate administrative action to take, if any, against the OIT employees involved in this particular matter.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/1/2015
We recommend that the COS confer with OGC and the Executive Director of the Office of Acquisition Operations (OAO) to determine the appropriate action to take against Systems Made Simple, Inc., for contractor employees failing to adhere to VA information security policies and contract security requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/16/2016
We recommend that the COS ensure that VA's information security policies are thoroughly reviewed and rewritten to address any weaknesses.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/11/2016
We recommend that the COS ensure that VA's information security training is thoroughly reviewed and rewritten to address any weaknesses.
Combined Assessment Program Review of the Dayton VA Medical Center, Dayton, Ohio
|
15-00073-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Special Care Unit Committee review each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Quality Council meet monthly and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Quality Council 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 store clean and dirty items separately and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility use special medication labeling and unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
No. 8
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 and that facility managers monitor compliance.
No. 9
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. 10
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. 11
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers revise local policies to require that radiology interpretation and computerized tomography coverage be available on call within 30 minutes.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that monthly inspections of the Mental Health Residential Rehabilitation Treatment Programs include all required elements.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Mental Health Residential Rehabilitation Treatment Program managers ensure that the programs have written agreements in place acknowledging resident responsibility for medication security.
Combined Assessment Program Review of the VA Puget Sound Health Care System, Seattle, Washington
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15-00069-199

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the Surgical Work Group include the Chief of Staff as a member.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the Safe Patient Handling Committee track patient handling injury data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended the facility ensure a third party conducts quality assurance reviews on a sample of the scanned documents.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that Environment of Care Board and Safety Committee minutes include corrective actions to address identified deficiencies and track those actions to closure.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that facility managers ensure community living center treatment carts containing resident care supplies are clean and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure critical medical equipment in the community living center is plugged into outlets that function in the event of a power loss and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that nursing reviewers sign the monthly medication review forms and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the facility’s recently chartered Consult Management Committee meet regularly and document oversight of consult management.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that Level 2 magnetic resonance imaging personnel review and sign secondary patient safety screening forms prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
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. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure the American Lake division follows local emergency airway management policy, or if the facility plans to perform intubations in areas designated to call 911, the facility updates the local emergency airway management policy and ensures privileged providers or clinicians with emergency airway management scope of practice are available.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure reporting of emergency airway management data to the designated committee with the frequency required by local policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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14-04391-162

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Jackson VA Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that employees at the Jackson VA Outpatient Clinic receive the required training on hazardous materials.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Jackson VA Outpatient Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that fire drills are performed every 12 months at the Jackson VA Outpatient Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that the information technology server closet at the Jackson VA Outpatient Clinic 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: 11/2/2015
We recommended that the staff at the Jackson VA Outpatient Clinic receive regular information/updates on their responsibilities in emergency response operations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
We recommended that the staff at the Jackson VA Outpatient Clinic participate in scheduled emergency management training and exercises.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of West Palm Beach VA Medical Center, West Palm Beach, Florida
|
15-00113-161

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Delray Beach, FL, CBOC and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that patient-identifiable information on laboratory specimens is protected during transport from the Delray Beach, FL, CBOC to the parent facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Delray Beach, FL, CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that Registered Nurse Care Managers, 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: 7/20/2016
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: 8/31/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Combined Assessment Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
|
15-00072-160

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the Environment of Care Committee gather, track, and share patient handling injury data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the facility conduct contrast reaction drills in magnetic resonance imaging and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility ensure all designated Level 1 ancillary staff and all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
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 mangers monitor compliance.
Combined Assessment Program Review of the West Palm Beach VA Medical Center, West Palm Beach, Florida
|
15-00071-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that facility managers ensure that emergency airway management privileges granted are appropriate for the practitioners' skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the Cardiopulmonary Resuscitation Committee 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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document did not meet image quality controls and a correction process if scanned items have errors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that Environment of Care Committee minutes include consistent discussion of rounds deficiencies, trends, and actions and tracking of actions to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that infection prevention and control meeting minutes consistently reflect discussion of identified high-risk priority areas.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that facility managers ensure patient care areas and public restrooms are clean and toilet paper dispensers are in good repair and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility secure medication carts when not in use and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and in the Emergency Department and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
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)
Closure Date: 9/22/2015
We recommended that the facility update the local consult policy for policy changes and review the policy at least every 3 years and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility conduct contrast reaction and fire emergency drills in magnetic resonance imaging and that the facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended that the facility conduct initial patient safety screenings and that the facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
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 the facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility 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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended that facility managers ensure that all nursing employees who perform 12-lead electrocardiograms have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2016
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the 2B-ICU.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility revise the emergency airway management policy to include a specific plan to manage difficult airways.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements, including a written test, and that facility managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
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.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
Healthcare Inspection – Patient Telemetry Monitoring Concerns, Michael E. DeBakey VA Medical Center, Houston, Texas
|
14-03927-197

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)
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
|
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
|
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
|
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
|
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
|
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
|
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.
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