All Reports

Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA New York Harbor Healthcare System, New York, New York
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14-00934-221

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Harlem CBOC to the parent facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2014
We recommended that the information technology server closet at the Harlem CBOC is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that staff provide medication counseling/education as required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2014
We recommended that the chief of staff consistently ensure that all Designated Women's Health Providers are designated with the women's health indicator in the Primary Care Management Module.
Combined Assessment Program Review of the Washington DC VA Medical Center, Washington, DC
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14-02065-230

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the Chief of Staff reconsider Peer Review Committee membership to ensure that sufficient experienced senior physicians are regular members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that a local observation bed policy be implemented and that data about observation bed use be collected and analyzed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that processes be strengthened to ensure that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the Surgical Work Group meet monthly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
We recommended that processes be strengthened to ensure that electronic health record quality data is analyzed at least quarterly and that the review of electronic health record quality includes most services.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2015
We recommended that the quality control policy for scanning be revised to include the handling of external source documents.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that processes be strengthened to ensure that the Transfusion Committee members from Medicine and Anesthesia Services consistently attend meetings.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that processes be strengthened to ensure that Environment of Care Committee and Executive Committee of the Governing Body minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2015
We recommended that processes be strengthened to ensure that public restrooms are clean and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that the surveillance monitoring system on the locked mental health unit is on at all times and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that the electronic patient monitoring system on the Community Living Center West unit is inspected and checks documented and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2015
We recommended that processes be strengthened to ensure that all medications in the emergency department, on the dialysis unit, on the post-anesthesia care unit, and in the eye clinic are secured and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2017
We recommended that processes be strengthened to ensure that the medication list provided to the patient/caregiver at discharge is reconciled with the dosage and frequency ordered and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that processes be strengthened to ensure that progress notes in the electronic health record are individualized and accurate.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that contrast reaction and fire emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed prior to magnetic resonance imaging and documented in the electronic health record and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in the patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that all staff who may need to enter the magnetic resonance imaging area be designated as Level 1 ancillary staff.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended that processes be strengthened to ensure that all designated Level 1 and Level 2 staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that appropriate physical barriers be in place to restrict access to magnetic resonance imaging Zones III and IV.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at New Mexico VA Health Care System, Albuquerque, New Mexico
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14-00919-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that patients’ personally identifiable information is protected and secured at the Truth or Consequences CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff provide medication counseling/education as required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical executive/primary care leaders ensure that CBOC/Primary Care Clinic Designated Women’s He
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the chief of staff consistently ensure that all Designated Women’s Health Providers are designated with the women’s health indicator in the Primary Care Management Module.
Combined Assessment Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico
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14-02063-231

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently initiated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that processes be strengthened to ensure the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2015
We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in outlier data, bar codes that were unable to scan, and blood transfusions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that processes be strengthened to ensure that nurse call system alarms are functional and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2015
We recommended that stroke guidelines be posted in the emergency department, on the critical care units, and on the medical and surgical units.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2015
We recommended that processes be strengthened to ensure that staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Washington DC VA Medical Center, Washington, DC
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14-00921-223

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that managers ensure that external signage is installed that clearly identifies the building as a VA CBOC at the Southern Prince George's County CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that managers ensure all interior signs clearly identify the route to and location of the Southern Prince George's County CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2015
We recommended that the clinic entrance door access is Americans with Disabilities Act accessible at the Southern Prince George's County CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Southern Prince George's County CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that signage is installed at the Southern Prince George's County CBOC to clearly identify the location of all fire extinguishers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that signage is installed at the Southern Prince George's County CBOC to clearly identify emergency exits from any direction.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that the information technology server closet at the Southern Prince George's County CBOC is secured according to information technology safety and security standards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2015
We recommended that the CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training and health-coaching training within 12 months of appointment to Patient Aligned Care Teams.
Combined Assessment Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota
|
14-01294-224

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the Clinical Executive Council document its discussion of Peer Review Committee quarterly summary reports, including unusual findings or patterns.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that a local observation bed policy that includes all required elements be implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that the Surgical Staff Committee meet monthly, include the Chief of Staff as a member, and document its review of National Surgery Office reports.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed and data analyzed at least quarterly and that the review of electronic health record quality
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that infection prevention educational materials are available for eye clinic patients, visitors, and family members.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that processes be strengthened to ensure that employees reprocess ophthalmology lenses and pachymetry probes in accordance with manufacturers¿ instructions and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that processes be strengthened to ensure that patient learning assessments are documented within 8 hours of admission and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that stroke guidelines be posted on all acute inpatient units.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the facility collect and report to the VHA 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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that contrast reaction drills are conducted in the magnetic resonance imaging mobile unit at the Hot Springs division and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Inspection of VA Regional Office St. Louis, Missouri
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14-01497-188

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommended the St. Louis VA Regional Office Director develop and implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommended the St. Louis VA Regional Office Director develop and implement a plan to review for accuracy the 559 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: 12/30/2014
We recommended the St. Louis VA Regional Office Director implement a plan to ensure compliance with local policy requiring staff assigned to a specialized team process traumatic brain injury and special monthly compensation claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommended the St. Louis VA Regional Office Director clarify local policy by clearly defining which special monthly compensation claims require processing by a specialized team.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommended the St. Louis VA Regional Office Director implement a plan to ensure staff comply with local policy requiring Decision Review Officers to conduct second-signature reviews of special monthly compensation claims.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommended the St. Louis VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Combined Assessment Program Review of the South Texas Veterans Health Care System, San Antonio, Texas
|
14-01290-222

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that damaged doors and floors and rusted lockers in patient care areas are repaired and that ongoing maintenance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that physicians complete and document discharge progress notes or patient discharge instructions and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that clinicians complete and document the National Institutes of Health Stroke Scale for each stroke patient and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that staff who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that the facility collect and report to VHA 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that staff document the reasons for not providing restorative nursing services when those services are care planned and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2015
We recommended that processes be strengthened to ensure that the restorative registered nurse or designee signs and provides feedback, if indicated, on restorative aide notes.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that secondary patient safety screenings are reviewed by Level 2 magnetic resonance imaging personnel on the same day as the magnetic resonance imaging and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure 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 compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at West Texas VA Health Care System, Big Spring, Texas
|
14-00916-218

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that external signage clearly identifies the building as a VA CBOC at the Fort Stockton CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that managers maintain a clean and functioning environment of care at the Hobbs CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that managers ensure staff can access the electronic version of the chemical inventory at the Abilene and San Angelo CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that processes are improved to ensure the tracking of chemical inventories at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that the effectiveness of the panic alarm system is evaluated at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that a separate room is provided to store medical (infectious) waste at the Hobbs CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that fire drills are performed every 12 months at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Abilene and San Angelo CBOCs to the parent facility.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2015
We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Fort Stockton CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Fort Stockton CBOC.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that the information technology server closets at the Abilene, Fort Stockton, Hobbs, and San Angelo CBOCs are maintained according to information technology safety and security standards.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that the parent facility document Emergency Management Preparedness-specific training completed by the West Texas VA Health Care System CBOC clinical providers.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that staff provide medication counseling/education as required.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that staff document the evaluation of patient's level of understanding for the medication education.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at John D. Dingell VA Medical Center, Detroit, Michigan
|
14-00931-213

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to PACT.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2016
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2015
We recommended that staff provide medication counseling/education as required.
Healthcare Inspection – Quality of Care and Staff Safety Concerns at the Huntsville Community Based Outpatient Clinic, Huntsville, Alabama
|
14-01322-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director ensures that documentation of treatment with opioid medications meets Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that the Facility Director ensures that staff consistently document responses to abnormal test results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director ensures that patients are notified of test results within the defined timeframe and that notification is documented in accordance with Veterans Health Administration requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director ensures that staff adhere to the facility policy for the management of non-VA medical records.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensures that Community Based Outpatient Clinic provider privileges are in accordance with Veterans Health Administration requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensures the mental health standard operating procedure is updated to incorporate all procedures available for management of a mental health emergency at the Community Based Outpatient Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2015
We recommended that the Facility Director ensures that Community Based Outpatient Clinic panic alarms are functional.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that the Facility Director ensures that a pain management policy is implemented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director ensures that the quality of entries in the electronic health record is reviewed at least quarterly.
Administrative Investigation, Prohibited Personnel Practice and Preferential Treatment, National Cemetery Administration, VA Central Office
|
13-03899-216

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 12/9/2014
We recommend that the VA Chief of Staff confer with OHR and OGC to determine the appropriate corrective action to take, if any, as it relates to the two applicants listed on the certificate of eligibles who were not afforded the same preference in this hiring effort.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 12/9/2014
We recommend that the VA Chief of Staff confer with OGC to review any active contracts with Ms. Noonan to ensure there is no organizational conflict of interest, as well as determine the appropriateness of the sole-source one-to-one contracts, and take the appropriate corrective action, if any.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Grand Junction VA Medical Center, Grand Junction, Colorado
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14-00918-204

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2014
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Healthcare Inspection – Alleged Medication Cart Deficiencies and Unsafe Medication Administration Practices, Atlanta VA Medical Center, Decatur, Georgia
|
14-02396-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that the Facility Director ensure that an adequate number of fully functioning medication carts are available for nurses to administer medications safely and on time.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2015
We recommended that the Facility Director ensure that nurses document the reasons for late medication administration.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that the Veterans Integrated Service Network Director enhance processes to improve purchasing and contracting efficiency for patient care equipment and items.
Healthcare Inspection – Alleged Mismanagement in the Cardiac Catheterization Laboratory, VA Maryland Health Care System, Baltimore, Maryland
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13-02892-217

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that nurse staffing is appropriate for the volume and types of procedures performed in the cardiac catheterization laboratory and that the requisite nurse competencies are maintained.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that the policies and procedures regarding the rapid response team, code blue team, and Anesthesia Services are updated as needed to reflect desired practices for managing cardiac catheterization laboratory emergencies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that the staff receive training on updated policies and procedures regarding the rapid response, code blue team and Anesthesia Services.
Audit of NCA's Rural Veterans Burial Initiative
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13-03468-203

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 9/4/2015
We recommended the Under Secretary for Memorial Affairs establish a methodology to identify the number and percentage of served and unserved rural veterans throughout the Nation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 9/4/2015
We recommended the Under Secretary for Memorial Affairs publish a national map showing the areas and number of served and unserved rural veterans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/23/2015
We recommended the Under Secretary for Memorial Affairs establish performance goals for the percentage of rural and urban veterans served.
Review of VBA’s Special Initiative To Process Rating Claims Pending Over 2 Years
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13-03699-209

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2017
We recommended the Under Secretary for Benefits implement a plan toidentify all provisionally-rated claims and ensure the proper controls areentered in the electronic system to track, manage, and complete them.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2017
We recommended the Under Secretary for Benefits implement actions toinclude provisionally-rated claims in the rating inventory and correct theaging of provisional claims in pending workload statistics.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2017
We recommended the Under Secretary for Benefits implement a plan toexpedite final decisions on all issues in provisionally-rated claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/25/2016
We recommend the Under Secretary for Benefits implement actions to complete quality reviews to ensure accuracy of all provisionally rated claims processed under this special initiative.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 40,400,000.00
Review of Alleged Mail Mismanagement at VBA’s Baltimore VA Regional Office
|
14-03644-225

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff analyze and take appropriate actions to properly control the approximately 9,500 documents and 80 claims folders referenced in this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/29/2014
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff receive refresher training on proper mail handling procedures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office supervisory staff receive refresher workload management training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/8/2014
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff conduct quarterly desk audits as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/30/2015
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff assess the impact that mismanaged mail and claims processing actions had on benefits delivery and provide that information for our review.
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