All Reports

Inspection of VA Regional Office Jackson, Mississippi
|
13-00709-257

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and schedule medical reexaminations as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to review the 195 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration and local second-signature requirements for traumatic brain injury claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2013
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers within the VA Regional Office's jurisdiction.
Community Based Outpatient Clinic Reviews at Hunter Holmes McGuire VA Medical Center, Richmond, VA
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13-00026-258

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2013
We recommended that the PSB submits actions and recommendations for privileging and reprivileging to the MPSC and that meeting minutes reflect documents reviewed and the rationale for privileging or reprivileging at the Charlottesville and Emporia CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers minimize risks associated with the handling, storing, and disposing of hazardous materials in the hazardous waste storage room at the Charlottesville CBOC.
Combined Assessment Program Review of the Sioux Falls VA Health Care System, Sioux Falls, South Dakota
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13-01674-256

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scale scores upon change in condition and/or at discharge and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff revise interprofessional treatment plans when there are risk level changes and that compliance be monitored.
Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania
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13-01672-260

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that a process be established to track HPC consults that are not acted upon within 4 days of the request.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that processes be strengthened to ensure that HPC inpatients pain is consistently reassessed and that results are documented timely in EHRs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that monthly DCHV Program and SA domiciliary self-inspection documentation includes all required elements.
Community Based Outpatient Clinic Review at Jack C. Montgomery VA Medical Center, Muskogee, OK
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13-00026-259

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Community Based Outpatient Clinic Reviews at Amarillo VA Health Care System, Amarillo, TX and Northern Arizona VA Health Care System, Prescott, AZ
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13-00026-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that a process be established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians administer tetanus vaccines when indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that the PSB grants privileges consistent with the services provided at the Lubbock CBOC.
Community Based Outpatient Clinic Reviews at Edward Hines, Jr. VA Hospital, Hines, IL
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13-00026-251

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that managers ensure that patients with normal and abnormal cervical cancer screening results are notified within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2013
We recommended that managers ensure that all specified medical equipment receive PM according to local policy at the Kankakee CBOC.
Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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13-01123-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director ensure that the patient (case 1) endof-life care undergoes a quality review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director ensure that CLC staff are appropriately trained and competent to care for all CLC residents, regardless of the residents' special care needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director conduct a risk assessment of the electronic monitoring system and implement improvements, as indicated.
Community Based Outpatient Clinic Reviews at VA Butler Healthcare, Butler, PA
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13-00026-248

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that signage is installed to direct physically challenged patients to the handicapped accessible entrance of the Armstrong County CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure all exit routes be clearly identified at the Armstrong County CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2013
We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Armstrong County CBOC to the contracted processing facility.
Combined Assessment Program Review of the James A. Haley Veterans’ Hospital, Tampa, Florida
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13-01971-245

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2014
We recommended that processes be strengthened to ensure that all services are included in the review of EHR quality.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the MH units, corrective actions taken, and tracking of corrective actions to closure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that sterile storage rooms are secured at all times and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2014
We recommended that processes be strengthened to ensure that staff competency validation results and results of compliance with RME SOPs are reported to the Clinical Executive Board.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities have initial training and annual competency validation documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization have initial training and annual competency validation documented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that the SPS eyewash station is checked weekly and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that the SPS decontamination area is clean.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that monthly CS findings summaries and quarterly trend reports are provided to the facility Director consistently and timely.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that IC and tuberculosis risk assessments are conducted prior to construction project initiation.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York
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13-00897-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are initiated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that the local observation bed policy be revised to include all required elements and that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that the blood usage and review process includes the number of units that were outdated or otherwise discarded, the results of proficiency testing, and the results of inspections by government or private (peer) entities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled; that hard copy orders for 5 randomly selected dispensing activities are validated in all non-pharmacy CS areas; and that at the Batavia pharmacy, audit trails for destruction of 10 randomly selected drugs are consistently verified.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that staff are consistent in pressure ulcer documentation of location, stage, size, characteristics, risk scale score, and date acquired and whether the wound has improved or deteriorated during the admission or at the time of discharge.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that staff consistently perform and document daily skin inspections and/or daily risk scales.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that pressure ulcer education is provided to patients at risk for or with pressure ulcers and/or their caregivers.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that designated employees receive training on how to accurately document pressure ulcer findings and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that nurse managers monitor the staffing methodology that was implemented in December 2012.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Inspection of VA Regional Office San Juan, Puerto Rico
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13-00586-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries to the electronic record as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to review for accuracy the 132 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure effective second-signature reviews of traumatic brain injury claims decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/2/2014
We recommend the San Juan VA Regional Office Director develop and implement a plan to ensure staff completely and timely address all required elements of Systematic Analyses of Operations.
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
|
13-01673-240

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are reported timely to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
We recommended that processes be strengthened to ensure that inpatient bathrooms are clean and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that processes on the acute MH inpatient units be strengthened to ensure that nurses' stations and medication rooms are secured from unauthorized entry and that furniture meets safety requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive annual competency assessments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that the facility ensure the multidisciplinary committee responsible for construction and renovation oversight includes all required members.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that construction site inspection documentation includes all the required elements.
Combined Assessment Program Review of the VA Maryland Health Care System, Baltimore, Maryland
|
13-00896-234

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2014
We recommended that the local observation bed policy be revised to include all required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the events.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that the quality control policy for scanning includes linking the scanned documents to the correct record.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that oxygen tanks are properly secured and stored in a manner that distinguishes between empty and full tanks.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2014
We recommended that processes be strengthened to ensure that soiled utility rooms are secured at all times.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that EOC rounds are consistently conducted in the Annex building in accordance with VHA and local policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that facility policy be amended to include that CS Coordinators must have complete understanding of CS policies and the VHA inspection process and to include requirements for new CS inspector orientation and/or annual training thereafter.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2014
We recommended that the instructions for inspecting automated dispensing machines be amended to include monthly CS inspector reconciliation of 1 day's dispensing activity and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that processes be strengthened to ensure that acute care staff consistently provide and document completion of recommended PU interventions and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that the facility establish staff PU education requirements and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that nursing managers ensure compliance with all elements of the staffing methodology that was implemented in December 2012.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that the facility ensure that the multidisciplinary committee responsible for construction and renovation oversight includes all required members.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2014
We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted prior to construction project initiation.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Inspection of VA Regional Office Roanoke, Virginia
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12-04456-232

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 Benefits Administration (VBA)
Closure Date: 1/10/2014
We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2014
We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure claims processing staff timely schedule medical reexaminations when the reminder notifications are received.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2014
We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2014
We recommend the Roanoke VA Regional Office Director develop and implement a plan to review for accuracy the 709 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2014
We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure effective second signature reviews of traumatic brain injury claims decisions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2014
We recommend the Roanoke VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers within the VA Regional Office's jurisdiction.
Review of VA's Programs for Addressing Climate Change
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13-01846-235

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 Office of Management (OM)
Closure Date: 4/2/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer coordinate with the Acting Assistant Secretary of the Office of Human Resources and Administration to implement existing telework expansion plans for reducing greenhouse gas emissions and to encourage VA employees to use alternative forms of commuting.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/17/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce greenhouse gas emissions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/17/2014
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce fleet petroleum consumption.
VA's Federal Information Security Management Act Audit for Fiscal Year 2012
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12-01712-229

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 Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology fully develop and implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from last year.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central database to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology define and implement clear roles and responsibilities for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from last year.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnection and ownership information. (This is a repeat recommendation from last year.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement improved processes for updating key security documents such as risk assessments, security impact analyses, and security self assessments on at least an annual basis and ensure all required information accurately reflects the current environment and new risks in accordance with Federal standards. (This is a new recommendation.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement periodic access reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from last year.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from last year.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from last year.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement two-factor authentication for remote access throughout the agency. (This is a new recommendation.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement effective automated mechanisms to continuously identify and remediate security deficiencies on VA's network infrastructure, database platforms, and Web application servers. (This is a modified repeat recommendation from last year.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement a patch and vulnerability management program to address security deficiencies identified during our assessments of VA's Web applications, database platforms, network infrastructure, and work stations. (This is a modified repeat recommendation from last year.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement standard security configuration baselines for all VA operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement procedures to enforce a system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from last year.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement processes to ensure information system contingency plans are updated with the required information and lessons learned are communicated to senior management. (This is a modified repeat recommendation from last year.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology ensure that agreements for alternate processing sites have been established that define the roles and responsibilities for alternate locations in the event of a disaster. (This is a new recommendation.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology fully implement an automated 24-hour security event and incident correlation solution to monitor security for all systems interconnections, database security events, and mission-critical platforms supporting VA programs and operations. (This is a modified repeat recommendation from last year.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology identify all external network interconnections and ensure appropriate Interconnection Security Agreements and Memoranda of Understanding are in place to govern them. (This is a repeat recommendation from last year.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a modified repeat recommendation.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement effective continuous monitoring processes to identify and prevent the use of unauthorized application software, hardware (including personal storage devices), and system configurations on its networks. (This is a repeat recommendation from last year.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a repeat recommendation from last year.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology develop procedures to integrate information security costs into the capital planning process while ensuring traceability of Plans of Action and Milestones remediation costs to appropriate capital planning budget documents. (This is a repeat recommendation from last year.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement procedures for overseeing contractor-managed systems and ensuring information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from last year.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement mechanisms for updating the Federal Information Security Management Act systems inventory, including interfaces with contractor-managed systems, and annually review the systems inventory for accuracy. (This is a repeat recommendation from last year.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Acting Assistant Secretary for Information and Technology implement mechanisms to ensure all users with VA network access participate in and complete required VA-sponsored security awareness training. (This is a modified repeat recommendation from last year.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Assistant Secretary for Information and Technology develop mechanisms to ensure risk assessments accurately reflect the current control environment, compensating controls, and the characteristics of the relevant VA facilities.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Assistant Secretary for Information and Technology review and update all applicable position descriptions to better describe sensitivity ratings and better document employee personnel records and contractor files, including 'Rules of Behavior' instructions, annual privacy and Health Insurance Portability and Accountability Act of 1996 training certifications, and position sensitivity level designations.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Assistant Secretary for Information and Technology ensure appropriate levels of background investigations be completed for all applicable VA employees and contractors in a timely manner, implement processes to monitor and ensure timely reinvestigations on all applicable employees and contractors, and monitor the status of the requested investigations.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Assistant Secretary for Information and Technology reduce wireless security vulnerabilities by ensuring sites have an effective and up-to-date methodology to protect against the interception of wireless signals and unauthorized access to the network and ensure the wireless network is segmented and protected from the wired network.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommend the Assistant Secretary for Information and Technology identify and deploy solutions to encrypt sensitive data and resolve clear text protocol vulnerabilities.
Healthcare Inspection – Nursing Care in the Community Living Center for Spinal Cord Injury, Louis Stokes VA Medical Center, Cleveland, OH
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12-02186-227

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: 2/14/2014
We recommended that the Facility Director ensure that the staffing levels on the Long-Term Care Spinal Cord Injury unit be consistent with Veterans Health Administration's requirements and the facility's spinal cord injury Master Nurse Staffing Plan.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2014
We recommended that the Facility Director ensure that Long-Term Care Spinal Cord Injury nursing staff consistently provide and document resident care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2014
We recommended that the Facility Director ensure that Long-Term Care Spinal Cord Injury nurse managers take action to investigate and address staff conduct related issues.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2014
We recommended that the Facility Director ensure that float staff assigned to the Long-Term Care Spinal Cord Injury unit have the training and competencies required for the unit.
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