All Reports

Healthcare Inspection – Emergency Department Concerns, Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas
|
14-03212-295

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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 the Eastern Kansas Health Care System Director ensure that all patients who present to the Eastern Kansas Health Care System Emergency Department requesting an examination or treatment receive a medical screening examination and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommended that the Eastern Kansas Health Care System Director ensure Leavenworth VAMC Emergency Department and Primary Care Clinic nursing staff document required assessments and that compliance is monitored.
Combined Assessment Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas
|
14-02064-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Medical Executive Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and consistently document its review of National Surgical Office reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data from electronic health record quality reviews are analyzed at least quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Tissue and Transfusion Committee member from Anesthesia Service consistently attends meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that damaged optical examination chairs in the eye clinics are repaired or removed from service.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to VHA 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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that appropriate signage and barriers be in place at the Leavenworth division to restrict access to magnetic resonance imaging Zone III.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Magnetic Resonance Imaging Safety Committee and the Patient Safety Manager evaluate the identified potential safety and security risks and take appropriate actions.
Review of Alleged Data Manipulation at the VA Regioinal Office Houston, TX
|
14-04003-298

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2014
We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear, change, or cancel controls for claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2014
We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
Healthcare Inspection – Out of Operating Room Airway Management Concerns, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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13-04005-296

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that the facility’s out of operating room airway management policy is updated to include all Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2015
We recommended that the Facility Director ensure that processes be strengthened to complete out of operating room airway management training and competency requirements as outlined by Veterans Health Administration and local policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that processes be strengthened to provide out of operating room airway management coverage as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that highly portable video laryngoscope equipment is immediately available
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that analysis of the five patient care events identified in this report is completed as required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the Facility Director ensure that the scopes of practice are updated for non-licensed independent practitioners who perform out of operating room airway management.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Long Beach Healthcare System, Long Beach, California
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14-00927-293

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that panic alarms are tested, and testing is documented at the Santa Ana CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the parent facility's Emergency Management Committee evaluate emergency preparedness activities, participation in annual disaster exercise, and staff training/education related to emergency preparedness requirements at the Santa Ana CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that staff document that medication reconciliation is completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that staff provide medication counseling/education as required.
Inspection of VA Regional Office White River Junction, Vermont
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14-02889-310

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/9/2015
The VA Regional Office should implement a plan to ensure staff timely process rating reductions and medical reexamination requests for temporary 100 percent disability evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/9/2015
The VA Regional Office should conduct a review of the 33 temporary 100 percent disability evaluations remaining from the inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/1/2015
The VA Regional Office should provide staff with refresher training on the proper processing of special monthly compensation claims and implement a plan to assess the effectiveness of that training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/1/2015
The VA Regional Office should implement a plan to strengthen the additional level of review for special monthly compensation claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/9/2015
The VA Regional Office should implement a plan, and assess the effectiveness of the plan, to ensure completion, and adequate and continuous oversight of Systematic Analyses of Operations requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/9/2015
The VA Regional Office should implement a plan for training, and assess the effectiveness of the training, to ensure completion of Systematic Analyses of Operations requirements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/9/2015
The VA Regional office should implement a plan to ensure oversight and processing of benefit reduction cases.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bath VA Medical Center, Bath, New York
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14-00928-291

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers complete required training within 12 months of appointment to Patient Aligned Care Teams.
Combined Assessment Program Review of the Bath VA Medical Center, Bath, New York
|
14-02075-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that the Morbidity and Mortality Committee 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 clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the facility consistently 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.
Administrative Investigation, Conduct Prejudicial to the Government and Interference of a VA Official for the Financial Benefit of a Contractor, Veterans Health Administration, Procurement & Logistics Office, Washington, DC
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13-03065-304

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend that the PDUSH confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against Ms. Taylor.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against Mr. Ryan.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the VHA Lead Contracting Specialist.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Tennessee Valley Healthcare System, Nashville, Tennessee
|
14-00929-287

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that the CBOC is Americans with Disabilities Act accessible at the Maury County CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that managers ensure staff can access the electronic version of hazardous materials information at the Maury County CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that processes are improved to ensure the tracking of hazardous materials at the Maury County CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that the effectiveness of the panic alarm system is evaluated at the Maury County CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that signage is installed at the Maury County CBOC to clearly identify the location of fire all extinguishers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that medications are secured and accessible only by individuals who either dispense or administer medications at the Maury County CBOC, and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Maury County CBOC to the parent facility.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that that that the information technology server closet at the Maury County CBOC is maintained according to information technology safety and security standards.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that CBOC and 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.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that staff consistently provide patients with medication counseling and written medication information that includes the fluoroquinolone.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Inspection of VA Regional Office Seattle, Washington
|
14-01502-259

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Seattle VA Regional Office Director 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 Health Administration (VHA)
We recommend the Seattle VA Regional Office Director implement a plan to review for accuracy the 576 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Seattle VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on processing claims related to special monthly compensation and ancillary benefits and implement a plan to monitor the effectiveness of that training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Seattle VA Regional Office Director amend its secondary-review policy by reducing the special monthly compensation threshold for requiring second-signature reviews as a means of ensuring accuracy in processing these complex claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Seattle Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Community Based Outpatient Clinic Summary Report — Evaluation of CBOC Cervical Cancer Screening and Results Reporting
|
14-02198-284

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying ordering providers of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying women veterans of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Inspection of VA Regional Office Chicago, Illinois
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14-02357-270

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2015
We recommended the Chicago VA Regional Office Director conduct a review of the 581 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2015
We recommended the Chicago VA Regional Office Director provide oversight to ensure staff follow Veterans Benefits Administration guidance for establishing suspense diaries and processing reminder notifications.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/17/2015
We recommended the Chicago VA Regional Office Director ensure staff receive refresher training on the proper processing of special monthly compensation and ancillary benefits and implement a plan to ensure the effectiveness of the training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2015
We recommended the Chicago VA Regional Office Director develop and implement a plan to ensure completion of all Systematic Analyses of Operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/17/2015
We recommended the Chicago VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff take timely action on claims requiring rating decisions for reduction of benefits.
Review of Alleged Data Manipulation at the Los Angeles VA Regional Office
|
14-03736-273

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2014
We recommended the Los Angeles VA Regional Office Director take action to review and correct all entries the employee made in the electronic system on the 14 claims we identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2014
We recommended the Los Angeles VA Regional Office Director ensure monitoring of all employees’ work for the future to ensure that all work is performed in accordance with VBA policy.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Alexandria VA Health Care System, Pineville, Louisiana
|
14-00926-281

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 4
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. 5
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.
Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon
|
14-02072-283

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2015
We recommended that the facility implement a quality control policy for scanning that includes all required elements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
We recommended that processes be strengthened to ensure that infection prevention educational materials are available for eye clinic patients, visitors, and family members.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
We recommended that processes be strengthened to ensure that dirty items in the eye clinic are not stored in patient care areas and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2015
We recommended that processes be strengthened to ensure that employees reprocess ophthalmology pachymetry probes in accordance with manufacturer's instructions and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2015
We recommended that facility policy be amended to include that Controlled Substances Coordinators must be free from conflicts of interest, that controlled substances inspectors must be appointed in writing, and that annual updates for controlled substances inspectors include problematic issues identified through external survey findings and other quality control measures.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2015
We recommended that the facility develop instructions for inspections of automated dispensing machines.
No. 7
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 the medical information from non-VA hospitalizations is consistently scanned into the electronic health records and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2015
We recommended that processes be strengthened to ensure that licensed independent practitioners are notified of critical laboratory test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2016
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2016
We recommended that processes be strengthened to ensure that safety plans contain documentation of assessment of available lethal means and ways to keep the environment safe and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2015
We recommended that processes be strengthened to ensure that patients and/or their families receive a copy of the safety plan and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2015
We recommended that processes be strengthened to ensure that written agreements acknowledging resident responsibility for medication security are in place in the domiciliary and the Domiciliary Care for Homeless
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Minneapolis VA Health Care System, Minneapolis, Minnesota
|
14-00938-272

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2015
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2015
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: 11/16/2015
We recommended that clinical executive/primary care leaders ensure that CBOC/Primary Care Clinic Designated Women's Health Providers maintain proficiency as required for the provision of women's health care.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2015
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 John D. Dingell VA Medical Center, Detroit, Michigan
|
14-02069-268

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that auditory privacy is maintained in all intake areas, that managers stress to staff that sensitive patient information should not be discussed in public areas, and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that all designated eye clinic employees receive eye laser safety training with the frequency required by local policy and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that processes be strengthened to ensure that clinicians document patient/caregiver understanding of discharge instructions and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
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: 5/25/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
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: 7/27/2015
We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
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: 5/25/2015
We recommended that processes be strengthened to ensure that staff modify restorative nursing interventions as needed and document the modifications and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
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: 7/27/2015
We recommended that processes be strengthened to ensure that hand-off communication occurs between Physical Medicine and Rehabilitation Service and the community living center when residents are discharged from therapy to ensure that restorative nursing services occur.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on range of motion and resident transfers.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that staff document residents' restorative progress weekly and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Healthcare Inspection – Emergency Department Staffing and Patient Safety Issues, VA San Diego Healthcare System, San Diego, California
|
14-00271-265

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: 8/31/2015
We recommended that the System Director implement a policy that includes a plan for additional registered nurses, providers, and support staff to augment the Emergency Department in times of acute overload or disaster.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that the System Director review the orientation processes for registered nurses floating to the Emergency Department to ensure that the orientation provided is adequate and documented consistently.
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