Date Issued
|
Report Number
12-02387-59
All Reports
Date Issued
|
Report Number
14-00930-14
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Dothan and Wiregrass CBOCs.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that managers ensure that material safety data sheets are readily available to staff at the Wiregrass CBOC.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that managers ensure staff can access the electronic version of the hazardous materials inventory at the Dothan CBOC.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/9/2015
We recommended that processes are improved to ensure the tracking of chemical inventories at the Dothan CBOC.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that the effectiveness of the panic alarm system is evaluated at the Wiregrass CBOC.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that panic alarms are tested and testing is documented at the Dothan and Wiregrass CBOCs.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that no clean items are stored in the medical (infectious) waste storage room at the Wiregrass CBOC.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that signage is installed to identify the medical (infectious) waste storage room at the Wiregrass CBOC.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/21/2015
We recommended that computer screens are secured to eliminate viewing of personally identifiable information by unauthorized individuals at the Wiregrass CBOC.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that processes are improved to ensure the use of privacy screens on computers in high-traffic areas at the Wiregrass CBOC.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that the parent facility maintain evidence of the contractor’s compliance with facility required education, training, planning, and participation in annual disaster exercises for the Dothan and Wiregrass CBOCs.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that the parent facility’s Emergency Management Committee evaluate the Dothan and Wiregrass CBOCs’ emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 4/13/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 6/16/2017
We recommended that CBOC/Primary Care Clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
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. 16
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
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. 17
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
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. 18
to Veterans Health Administration (VHA)
Closure Date: 8/13/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 10/21/2015
We recommended that staff provide medication counseling/education as required.
Date Issued
|
Report Number
13-01859-42
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended the Interim Under Secretary for Health end the use of the answering machine and improve the utilization and accessibility of the National Call Center for Homeless Veterans current counselors before consideration is given to hiring additional staff.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health implement effective performance measures and benchmarks for the National Call Center for Homeless Veterans and performance standards for staff to ensure the accessibility of counselors, the efficient management of calls, and the proper referral of veterans' calls.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended the Interim Under Secretary for Health routinely monitor and analyze National Call Center for Homeless Veterans telephone system data to assess the quality of Call Center support services, including the counselors' accessibility, efficiency in answering calls, and issuance of referrals.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health ensure that Call Center officials adhere to Veterans Health Administration's National Call Center for Homeless Veterans policy requirements related to monitoring referred calls.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/18/2015
We recommended the Interim Under Secretary for Health implement management controls to ensure VA medical facilities receive feedback on the quality of their referral responses and on needed corrections and improvements to the homeless support services extended to referred veterans.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health review the results of this audit with the VA medical facilities' homeless points of contact to ensure they understand their responsibility to ensure referred veterans receive needed support services.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended the Interim Under Secretary for Health implement controls to ensure National Call Center for Homeless Veterans special purpose funds are used as intended.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 267,000.00
Date Issued
|
Report Number
14-05128-51
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended that the Facility Director review clinic productivity and implement a plan to enhance productivity in those clinics for which productivity is an issue.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director ensure clinical departments accurately capture provider workload.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director direct clinical departments to review labor mapping to ensure the labor mapping is up to date and accurately reflects the percentage of provider time allocated to direct patient care.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director review the quadrants into which mental health, primary care, and specialty care clinics appear on the VHA Specialty Productivity-Access Report and Quadrant (SPARQ) tool, and evaluate and address underlying factors.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director take measures to promote alignment of organizational structure with clinic centered accountability, goals, and expectations.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director revise policy and/or processes to facilitate primary care Patient Aligned Care Team (PACT) operation and support PACT model workflow and clinic-wide coordination of care.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director identify specialties particularly vulnerable to loss of a provider and explore contingency plans to potentially mitigate the impact of provider loss on clinic disruption.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director take measures to promote non-provider to provider communication within mental health, primary care, and specialty clinics.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/28/2015
We recommended the Facility Director consider inter-service agreements between primary care and specialty care clinics.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director direct MH clinic leadership to evaluate access and patient engagement for specific types of outpatient mental health services, including individual psychotherapy and intensive substance use treatment, in order to provide a more encompassing picture of MH access.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/30/2015
We recommended the Facility Director provide a quarterly update on facility efforts to revise outpatient MH clinic processes to promote greater continuity of care through the regular outpatient MH clinic and to better focus the walk-in clinic toward serving those in need of walk-in care.
Date Issued
|
Report Number
14-02081-41
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that the Surgical Work Group meet monthly, include the Chief of Staff as a standing member, and document its review of National Surgical Office reports.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed at least quarterly.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that the Medical Records Committee meet quarterly.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Function Team meeting minutes document those actions.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that processes be strengthened to ensure that rolling equipment and patient weight scales are cleaned on a routine basis and that damaged furniture in patient care areas is repaired or removed from service.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the eye clinic waiting room carpet be replaced to avoid tripping hazards.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the facility's stroke policy be revised to address screening patients for difficulty swallowing and the difference in approach to patients presenting within and after 2 hours of onset of symptoms, that the policy be fully implemented, and that compliance be monitored.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
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. 11
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
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. 14
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the facility collect and report to the Provision of Care Committee the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that processes be strengthened to ensure that clinicians obtain a partial thromboplastin time test while assessing patients presenting with stroke symptoms and that compliance be monitored.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommend that that processes be strengthened to ensure that initial patient safety screenings are conducted and documented in the electronic health records and that compliance be monitored.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommend that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that facility policy be revised to fully meet VHA requirements and that processes be strengthened to ensure that quarterly Magnetic Resonance Imaging Safety Committee meetings are held and biannual magnetic resonance imaging safety inspections are conducted and that compliance be monitored.
Date Issued
|
Report Number
14-02080-29
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff document monthly restorative nursing services progress notes in residents’ electronic health records and that compliance be monitored.
No. 2
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that residents are offered transfer from their wheelchairs to regular dining chairs during meal periods.
No. 3
to Veterans Health Administration (VHA)
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 record.
Date Issued
|
Report Number
14-02079-10
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that code data is collected.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/25/2014
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee representatives from Surgery and Anesthesia Services consistently attend meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Prevention Committee minutes document those actions, reflect follow-up on actions implemented to address identified problems, and consistently reflect analysis of surveillance activities.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that processes be strengthened to ensure that fluoroquinolone dosages and/or medications ordered at discharge are consistent with the discharge instructions and the pharmacy updates provided to the patient/caregiver and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the electronic health records and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/22/2016
We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/22/2016
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
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that stroke guidelines be posted on the intensive care unit and the acute medical/surgical unit and that the facility provide a stroke educational program for employees.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/22/2016
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that care plans are updated when community living center residents’ restorative care needs change and that all residents are reassessed for restorative nursing needs at the intervals required by local policy.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify restorative nursing interventions as needed, and document those modifications and that compliance be monitored.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Minimum Data Set Coordinator collaborate with the Restorative Nurse to communicate pertinent minimum data set and quality indicator data to restorative nursing program staff.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility establish written procedures for handling emergencies in magnetic resonance imaging and that compliance be monitored.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that processes be strengthened to ensure that contrast reaction drills are conducted in magnetic resonance imaging and that compliance be monitored.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that secondary patient safety screening forms are scanned into the patients’ electronic health records and that compliance be monitored.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
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. 21
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that processes be strengthened to ensure that patients with positive colorectal cancer screening test results receive diagnostic testing within the required timeframe and that compliance be monitored.
Date Issued
|
Report Number
14-02078-38
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that the Quality Management Board meet at least quarterly.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Executive Committee of the Medical Staff.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/25/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are initiated.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that the Executive Committee of the Medical Staff discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that processes be strengthened to ensure that all specialty clinic employees receive annual bloodborne pathogens training.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that eye clinic exam/procedure room sinks have foot controls, long-blade handles, or automatic no touch sensors.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/25/2015
We recommended that processes be strengthened to ensure that the medical information from non-VA hospitalizations is consistently scanned into the electronic health record and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that processes be strengthened to ensure that clinicians document acknowledgement of their patients¿ recent non-VA hospitalizations.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that processes be strengthened to ensure that all patients are notified of abnormal Pap smear results/values within the expected timeframe and that notification is documented in the electronic health record and that compliance be monitored.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that processes be strengthened to ensure that all patients are notified of normal lab results/values and radiology results within the expected timeframe and that notification is documented in the electronic health record.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
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
to Veterans Health Administration (VHA)
Closure Date: 5/26/2015
We recommended that processes be strengthened to ensure that all employees receive Level 1 training and that the training be documented in employee training records.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that processes be strengthened to ensure that residential rehabilitation unit employees perform and document daily inspections for unsecured medications and that compliance be monitored.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that a process be in place to alert residential rehabilitation unit employees when alarmed doors that are not considered main points of entry are opened from the inside and that the process be tested regularly.
Date Issued
|
Report Number
14-00661-43
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015
We recommended that the Facility Director strengthen processes to ensure that patients are involved in the scheduling process, that program managers periodically monitor exam cancelations, and that staff accurately document patient dispositions and actions taken related to patient scheduling.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that the Facility Director ensure that clinicians review the electronic health records of the two patients who had unfulfilled computed tomography orders to determine whether follow-up actions are needed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/24/2014
We recommended that the Facility Director monitor compliance with the facility's newly implemented scheduling policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director ensure that proper equipment and software is available for uploading non-VA images and that staff are trained.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director ensure that program managers periodically assess and monitor the appropriateness of early walk-in ultrasound clinic closure and take necessary steps to ensure outpatients receive timely studies.
Date Issued
|
Report Number
13-01545-11
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs limit future use of time and materials contracts to those instances where the extent or duration of the work cannot be anticipated with any reasonable degree of confidence.
No. 2
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that significant new contract requirements are solicited in lieu of merely modifying existing contracts to meet new needs.
No. 3
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that contractor billings are approved based on sufficient documentation to demonstrate that contractors are meeting performance-based requirements.
No. 4
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs implement improved oversight of contractor activities to ensure they are appropriate to meet contract terms and do not include inherently Governmental functions.
No. 5
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs develop and implement program performance metrics to determine whether outreach and awareness campaigns are improving veterans’ awareness of and access to VA services and benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,000,000.00
Date Issued
|
Report Number
12-02576-30
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health implement a quality assurance program that provides sufficient oversight to ensure that contracting issues are corrected by the responsible contracting office.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health implement a mechanism to facilitate and ensure contracting officers’ performance can be objectively evaluated against their performance standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health monitor contracting officer performance deficiencies and ensure training is provided to correct identified deficiencies.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health ensure contracting staff complete Integrated Oversight Process reviews in accordance with established policies and contracting officers’ performance standards.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/28/2016
We recommended the Interim Under Secretary for Health revise Integrated Oversight Process review procedures to include a review to ensure Advisory and Assistance services are identified and approved.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended the Interim Under Secretary for Health ensure that contracting officers delegate in writing contracting officers’ representatives requirements and authorities to monitor contracts, as required by Federal and VA acquisition policy and contracting officers’ performance standards.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended the Interim Under Secretary for Health ensure that contracting officers conduct and document quarterly meetings with contracting officers’ representatives as required by VA acquisition policy.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 795,000,000.00
Date Issued
|
Report Number
14-02083-24
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that processes be strengthened to ensure that providers complete and document patient discharge progress notes or discharge instructions and that compliance be monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
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. 4
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
Date Issued
|
Report Number
14-02101-09
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director develop and implement a plan to review for accuracy the 138 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on identifying and returning insufficient medical examination reports related to traumatic brain injury claims to medical facilities for correction.
No. 3
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration’s second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing these claims to identify local training needs.
No. 4
to Veterans Health Administration (VHA)
The Huntington VA regional Office Director develops and implements a plan to ensure staff complies with local second-signature requirements for processing special monthly compensation.
No. 5
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
No. 6
to Veterans Health Administration (VHA)
The Huntington VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans
Date Issued
|
Report Number
14-01519-40
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible institutional disclosure.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended the Network Director conduct a thorough review of the Northern Indiana Health Care System Mental Health Service’s processes and leadership.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure providers’ electronic health record documentation is consistent with VHA Handbook 1907.01, Health Information Management and Health Records, especially in regards to discharge instructions and summaries, patient problem lists, and critical telephone and fax communications, as discussed in this report.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director ensure that Northern Indiana Health Care System Non-VA Care Coordination staff case manage patients consistent with their current functional statements or that the role of Non-VA Care Coordination staff be reassessed and functional statements changed to reflect tasks actually performed by the Non-VA Care Coordination staff.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director ensure that all Northern Indiana Health Care System providers receive ongoing professional practice evaluations consistent with VHA Directive 1100.19, Credentialing and Privileging.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that responsible clinical staff review the patient’s electronic health record and initiate appropriate follow-up action consistent with VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, when a patient is a “no show.”
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that the Northern Indiana Health Care System Director develop guidelines for documenting and responding to secure messages.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that Northern Indiana Health Care System mental health patients be assigned a Mental Health Treatment Coordinator and that a process is in place to reassign coordinators in the event of staff departure consistent with the Deputy Undersecretary for Health for Operations and Management’s “Assignment of the Mental Health Treatment Coordinator” and local policy requirements.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that Northern Indiana Health Care System Community Based Outpatient Clinic mental health services are provided consistent with VHA Directive 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure processes are in place at the Northern Indiana Health Care System to ensure continuity of mental health care in the event of staff departure and/or reassignment.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that the Network Director ensure Northern Indiana Health Care System telephone triage, suicide prevention program, and emergency department staff receive training regarding expected psychiatric emergency response.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure Northern Indiana Health Care System providers implement stepped consultative care and integrate behavioral health with the primary care of chronic pain consistent with VHA Directive 2009-053, Pain Management.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 8/17/2015
We recommended that the Network Director ensure that Richard L. Roudebush VA Medical Center Clinical Application Coordinators remove Computerized Patient Record System consult order templates from facility ordering systems when a consult service is no longer offered.
Date Issued
|
Report Number
13-03221-08
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director conduct a review of the 70 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director provide oversight to ensure staff follows Veterans Benefits Administration guidance related to processing reminder notifications for medical reexaminations.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/16/2015
We recommended the Providence VA Regional Office Director ensure staff receive refresher training on proper evaluation of traumatic brain injury and special monthly compensation and ancillary benefits claims and implement plans to ensure the effectiveness of that training.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director develop and implement a plan to ensure timely completion of Systematic Analyses of Operations.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 3/18/2015
We recommended the Providence VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff takes timely action on claims requiring rating decisions for reduction of benefits.
Date Issued
|
Report Number
14-01504-32
Date Issued
|
Report Number
14-02084-16
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that completed actions from peer reviews are consistently documented in Peer Review Committee meeting minutes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that the Surgical Work Group meet monthly.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/6/2015
We recommended that processes be strengthened to ensure that the Blood Utilization Committee representative from Anesthesia Service consistently attends meetings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/14/2015
We recommended that processes be strengthened to ensure that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/14/2015
We recommended that processes be strengthened to ensure that the negative pressure control systems in the dialysis isolation rooms are functional and that the dialysis unit water treatment, sterile supply, clean utility, and soiled utility room doors are secured at all times and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that processes be strengthened to ensure that equipment is not stored in the restraint room on the locked mental health unit and that compliance be monitored.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that documentation of pachymetry probe reprocessing in the eye clinic is in accordance with the manufacturer’s instructions and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
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, document resident progress towards restorative nursing goals, and document reasons why care planned restorative nursing services were not provided or were discontinued and that compliance be monitored.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
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 potential contraindications prior to the scan and that compliance be monitored.
Date Issued
|
Report Number
14-00937-31
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that processes are improved to ensure compliance with requirements for hazardous materials, including tracking of hazardous materials inventories at the Martinez CBOC, reviewing these inventories twice within a 12-month period at the Martinez and Redding CBOCs, and training Martinez CBOC staff to ensure access to the electronic version of the material safety data sheets.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Fairfield and Martinez CBOCs to the parent facility or contracted processing facility, by securing patient data in the Health Education Room, and through the use of privacy screens on computer monitors at the Martinez Primary Care check-in desk.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that the parent facility’s Emergency Management Committee includes the CBOC in required education, training, planning, and participation leading up to the annual disaster exercise and evaluates the Fairfield, Martinez, and Redding CBOCs’ emergency preparedness activities and participation in annual disaster exercises.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
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. 5
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
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. 7
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that staff provide and document medication counseling/education as required.
Date Issued
|
Report Number
14-02577-07
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to review the 206 temporary 100 percent disability evaluation claims remaining from our inspection universe and take appropriate actions.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level Special Monthly Compensation and Ancillary Benefits.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure Systematic Analysis of Operations contain thorough analyses, use appropriate data, and include all recommendations needed, along with time frames for implementation.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 4/16/2015
We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Date Issued
|
Report Number
14-00939-27
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended that the Pembroke Pines CBOC location is clearly identified from the street as a VHA CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that the main entrance and restroom doors at the Key Largo CBOC are accessible per Americans with Disabilities Act guidelines.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/10/2014
We recommended that signage is installed at the Pembroke Pines CBOC to clearly identify the location of fire extinguishers.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that exit signs are visible from all directions at the Key Largo CBOC.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that personally identifiable information is protected by securing laboratory specimens during transport from the Key Largo and Pembroke Pines CBOCs to the parent facility.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that clinic staff provide adequate privacy for women veterans at the Key Largo and Pembroke Pines CBOCs.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that access to the information technology server closet at the Key Largo CBOC is documented.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/9/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that staff consistently document and provide written medication information that includes the fluoroquinolones.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that staff consistently document and provide medication counseling/education as required.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/17/2015
We recommended that staff consistently document the evaluation of patient's level of understanding for the medication education.