All Reports

Combined Assessment Program Review of the South Texas Veterans Health Care System, San Antonio, Texas
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14-01290-222

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

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

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

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

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 12/9/2014
We recommend that the VA Chief of Staff confer with OHR and OGC to determine the appropriate corrective action to take, if any, as it relates to the two applicants listed on the certificate of eligibles who were not afforded the same preference in this hiring effort.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 12/9/2014
We recommend that the VA Chief of Staff confer with OGC to review any active contracts with Ms. Noonan to ensure there is no organizational conflict of interest, as well as determine the appropriateness of the sole-source one-to-one contracts, and take the appropriate corrective action, if any.
Healthcare Inspection – Alleged Medication Cart Deficiencies and Unsafe Medication Administration Practices, Atlanta VA Medical Center, Decatur, Georgia
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14-02396-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that the Facility Director ensure that an adequate number of fully functioning medication carts are available for nurses to administer medications safely and on time.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2015
We recommended that the Facility Director ensure that nurses document the reasons for late medication administration.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that the Veterans Integrated Service Network Director enhance processes to improve purchasing and contracting efficiency for patient care equipment and items.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Grand Junction VA Medical Center, Grand Junction, Colorado
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14-00918-204

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2014
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Healthcare Inspection – Alleged Mismanagement in the Cardiac Catheterization Laboratory, VA Maryland Health Care System, Baltimore, Maryland
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13-02892-217

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

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

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

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff analyze and take appropriate actions to properly control the approximately 9,500 documents and 80 claims folders referenced in this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/29/2014
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff receive refresher training on proper mail handling procedures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2015
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office supervisory staff receive refresher workload management training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/8/2014
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff conduct quarterly desk audits as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/30/2015
We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff assess the impact that mismanaged mail and claims processing actions had on benefits delivery and provide that information for our review.
Audit of Post-9/11 G.I. Bill Monthly Housing Allowance and Book Stipend Payments
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13-01452-214

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/13/2017
We recommended the Under Secretary for Benefits ensure the Post-9/11 G.I. Bill application provides veterans with clear, adequate information on educational benefits and the requirement to relinquish other education benefits before submission.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/26/2014
We recommended the Under Secretary for Benefits determine and establish a timeliness standard for the submission of initial enrollment certifications and a mechanism to monitor school certifying officials’ compliance with the submission of initial enrollment certifications and changes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/26/2014
We recommended the Under Secretary for Benefits reinforce the need for school certifying officials to complete available Veterans Benefit Administration online training on the timely and accurate reporting of enrollments and changes through the Veterans Affairs Online Certification Enrollment system.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/26/2014
We recommended the Under Secretary for Benefits ensure Education Service establishes a monitoring mechanism to include reviews of enrollment changes in its quarterly quality reviews of Regional Processing Office claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2023
We recommended the Under Secretary for Benefits ensure Long Term Solution calculations for book stipends align with the regulatory requirements established for students who are enrolled at 50 percent or less.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/26/2014
We recommended the Under Secretary for Benefits ensure Veterans Benefit Administration Regional Processing Office staff regularly update school information in the Web Enabled Approval Management System and include accurate full-time equivalency information in the schools’ profiles.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/3/2016
We recommended the Under Secretary for Benefits reconcile Education Service procedures and Federal regulations and decide whether or not book stipends will be recovered from students who withdraw from courses without mitigating circumstances.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/2/2015
We recommended the Under Secretary for Benefits ensure the Veterans Benefits Administration collects outstanding improper payments identified by this audit as defined by the Improper Payments Elimination and Recovery Act.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 205,000,000.00
Inspection of the VA Regional Office New Orleans, LA
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14-01053-172

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director conduct a review of the 329 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director implement a plan to assess the effectiveness of their recent training on processing traumatic brain injury claims and special monthly compensation benefits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director implement a plan to emphasize that rating staff address all ancillary benefits, even if not expressly claimed, to ensure veterans receive maximum entitlement to benefits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director implement a plan to ensure Systematic Analyses of Operations contain all required elements including specific timeframes for completion of recommendations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director ensure that staff receive training on VBA policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director develop and implement a plan to ensure staff prioritize processing of benefit reductions at the expiration of due process as required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommend the New Orleans VA Regional Office Director provide training on the proper procedures for benefit reductions and implement a plan to assess the effectiveness of that training.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Robert J. Dole VA Medical Center, Wichita, Kansas
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14-00915-206

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that processes are improved to ensure hazardous materials are inventoried and tracked at the Parsons CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that a panic alarm system is installed at the Parsons CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that fire drills are performed every 12 months at the Parsons CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Parsons CBOC to the parent facility or contracted processing facility.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Parsons CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2015
We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Parsons CBOC.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that all identified environment of care deficiencies at the Parsons CBOC are reported to and tracked by the parent facility¿s Environment of Care Committee until resolution.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that the parent facility include staff at the Parsons CBOC in required education, training, planning, and participation in annual disaster exercises.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that the parent facility document Emergency Management Preparedness-specific training completed for the Parsons CBOC clinical providers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that the parent facility's Emergency Management Committee evaluate the Parsons CBOC's emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that staff provide medication counseling/education as required.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that staff document the evaluation of patient's level of understanding for the medication education.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2014
We recommended that the chief of staff consistently ensures that all Designated Women's Health Providers are designated with the women's health indicator in the Primary Care Management Module.
Follow-Up Audit of VHA's Workers' Compensation Case Management
|
11-00323-169

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended the Acting Under Secretary for Health establish Workers’ Compensation Program case file documentation standards so that specialists ensure case files are complete (repeat recommendation from the 2004 and 2011 VA Office of Inspector General audit reports).
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended the Acting Under Secretary for Health establish a directive mandating Workers’ Compensation Program specialists implement the workers’ compensation guidebook to ensure specialists question the validity of claims lacking adequate supporting evidence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2016
We recommended the Acting Under Secretary for Health establish a structure with a clear chain of command to ensure workers’ compensation compliance with case management requirements, oversight, and policy enforcement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2016
We recommended the Acting Under Secretary for Health implement controls to ensure workers’ compensation staff who are responsible for case management make job offers to medically able employees (repeat recommendation from the 2004 and 2011 VA Office of Inspector General audit reports).
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2016
We recommended the Acting Under Secretary for Health ensure medical center directors assign adequate staff to manage Workers’ Compensation Program cases (repeat recommendation from the 2004 and 2011 VA Office of Inspector General audit reports).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended the Acting Under Secretary for Health develop and implement fraud identification and referral procedures (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 95,100,000.00
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
|
14-00910-205

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
We recommended that managers ensure staff can access the electronic version of the inventory of hazardous materials at the Yakima CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2015
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Yakima CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed or modified.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2015
We recommended that staff document the evaluation of patient's level of understanding for the medication education.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
We recommended that clinical executive/primary care leaders ensure that CBOC/PCC Designated Women's Health Providers maintain proficiency as required for the provision of women's health care.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at James J. Peters VA Medical Center, Bronx, New York
|
14-00932-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2014
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Yonkers CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2014
We recommended that the information technology server closet at the Yonkers CBOC is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2014
We recommended that processes are improved to ensure that only information technology and other official telephone and electrical equipment are stored in the Yonkers CBOC information technology server closet.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2015
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2015
We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2015
We recommended that CBOC/PCC Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Black Hills Health Care System, Fort Meade, South Dakota
|
14-00909-191

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that signage is installed at the Scottsbluff CBOC to clearly identify the location of fire extinguishers.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Scottsbluff CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that staff document the evaluation of patient¿s level of understanding for the medication education.
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