All Reports

Community Based Outpatient Clinic and Primary Care Clinic Reviews at Southern Arizona VA Health Care System, Tucson, Arizona
|
14-00240-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Casa Grande CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2015
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Casa Grande, Green Valley, and Safford CBOCs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2015
We recommended that the information technology server closets at the Green Valley and Safford CBOCs are maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2015
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coach 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: 6/18/2015
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: 6/18/2015
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 El Paso VA Health Care System, El Paso, Texas
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14-00241-128

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that external signage clearly identifies the building as a VA CBOC at the Eastside El Paso CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2015
We recommended that testing of the panic alarm system is documented at the Eastside El Paso CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2015
We recommended that staff document the evaluation of patient¿s level of understanding for the medication education.
Combined Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania
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14-00683-130

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that results of completed FPPEs for newly hired licensed independent practitioners are consistently reported to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that Transfusion Committee members from Surgery and Anesthesia Services consistently attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2015
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated after initial use and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff, ISIT members, and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing includes VA Police response time and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that MH EOC Checklist inspections include participation by all required ISIT members and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that the ISIT assigns a risk level per identified deficiency at the time of acute MH unit inspections and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that nursing managers implement VHA's staffing methodology.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2015
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections and daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2014
We recommended that processes be strengthened to ensure that all designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that staff do not provide medical treatments to residents during meals in the common dining area.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern Indiana Health Care System, Fort Wayne, Indiana
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14-00239-127

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that Community Based Outpatient Clinic/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2014
We recommended that Community Based Outpatient Clinic/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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that clinical executive/primary care leaders ensure that Community Based Outpatient Clinic/Primary Care Clinic Designated Women’s Health Providers maintain proficiency as required for the provision of women’s health care.
Audit of VHA's Engineering Service Purchase Card Practices at the Ralph H. Johnson VAMC, Charleston, SC
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13-02267-124

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2015
We recommend the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 to identify unauthorized commitments, and submit ratification requests for the unauthorized commitments identified by the Office of Inspector General and by Veterans Integrated Service Network 7 to the Veterans Health Administration Head of Contracting Activity.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2015
We recommended the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high-risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 for purchases lacking sufficient documentation and take steps to recover identified inappropriate payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2014
We recommended the Veterans Integrated Service Network 7 Director develop monitoring mechanisms to ensure Charleston VA Medical Center Engineering Service approving officials consistently use Veterans Health Administration’s required Approving Official Checklist to identify split purchases, purchases that exceed the micro-purchase limit for services, and purchases without sufficient documentation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2014
We recommended the Veterans Integrated Service Network 7 Director ensure Charleston VA Medical Center Engineering Service’s purchase cardholders and approving officials receive required refresher training every 2 years.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 646,000.00
Combined Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama
|
14-00307-126

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the MEC document discussion of PRC quarterly summary reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the MEC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with the new observation bed policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data about observation bed use continues to be gathered.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of the patients in acute beds.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode, that code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code, and that code data is collected.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and document its review of required monthly and quarterly performance data elements, including local performance data and National Surgical Office reports.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that members from Medicine, Surgery, and Anesthesia Services attend Transfusion Process Committee meetings and that the blood/transfusions usage review process includes the results of proficiency testing.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Infection Control Committee minutes reflect follow-up on actions that were implemented to address identified problems.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers continue to monitor the staffing methodology that was implemented in November 2012.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with the revised pressure ulcer policy as it pertains to prevention for outpatients.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the newly established Interprofessional Pressure Ulcer Committee meet as required and that the committee provide oversight of the facility’s pressure ulcer prevention program.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pressure ulcer data is analyzed and that program data is reported to facility executive leadership.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stage in initial skin assessments for patients at risk or with pressure ulcers and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff develop interprofessional treatment plans for all hospitalized patients identified as being at risk for or with pressure ulcers and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
FY 2013 Review of VA's Compliance With the Improper Payments Elimination and Recovery Act
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13-02926-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended the Under Secretary for Health implement the corrective action plan included in the Performance and Accountability Report to reduce improper payments for the State Home Per Diem program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2014
We recommended the Under Secretary for Health develop achievable reduction targets for the State Home Per Diem and Beneficiary Travel programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2014
We recommended the Under Secretary for Benefits ensure thorough procedures for testing sample items used to estimate improper payments for the Compensation and Post 9/11 G.I. Bill programs.
Administrative Investigation, Failure to Comply with Americans with Disabilities Act and VA Policy, Veterans Health Administration
|
13-02649-120

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2014
We recommend that the Deputy Under Secretary for Health Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2014
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommend that the DUSHOM confer with OGC and OHRI to determine and execute a plan to provide all VHA employees involved in the RA process, as well as Regional Counsels who provide them advice, the most up to date RA training and guidance, and direct all VHA employees to process RA requests in accordance with applicable Federal laws and regulations and VA policy.
Combined Assessment Program Review of the Southern Arizona VA Health Care System, Tucson, Arizona
|
14-00305-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that the Surgical Work Group meet monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that patient care areas in the CLC are clean and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that walls in the CLC are repaired and maintained.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that processes be strengthened to ensure that all workers who occasionally access the acute MH receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA’s National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that clinicians identify post-discharge needs and include them in discharge planning.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services within the ordered/expected timeframe.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in May 2013.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2014
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff revise the prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale and how to conduct a complete skin assessment and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that processes be strengthened to ensure that staff document weekly summaries of restorative nursing services in residents’ EHRs.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Lebanon VA Medical Center, Lebanon, Pennsylvania
|
14-00234-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that fire drills are performed every 12 months at the Reading CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that CBOC and PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that CBOC and PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2014
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.
Combined Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California
|
14-00658-121

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2014
We recommended that the Blood Usage Review Sub-Committee include a clinical representative from Medicine Service as a member.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes consistently reflect EOC findings from community based outpatient clinic inspections.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that processes be strengthened to ensure patient care areas are clean and that water leaks and subsequent structural damage are addressed and resolved timely and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that processes be strengthened to ensure that expired medical supplies and medications are removed from patient care areas and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2014
We recommended that all emergency exits on the locked MH unit be alarmed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the EHRs and that they validate patients' and/or caregivers' understanding of the discharge instructions they provided and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2014
We recommended that the annual staffing plan reassessment process ensures that unit 2NE's and unit 4SW's unit-based expert panels include all required members and that all members of the unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that nurse managers reassess the target nursing hours per patient day for unit 2NE to more accurately plan for staffing and evaluate the actual staffing provided.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2015
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings, and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
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.
Combined Assessment Program Review of the Portland VA Medical Center, Portland, Oregon
|
14-00309-118

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that the Operative Care Division Quality and Performance Group meet monthly, include the COS as a member, and document its review of National Surgical Office reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that all emergency exits on the locked MH unit be alarmed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing includes VA Police response time and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that clinicians conducting medication counseling accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that the facility have a Veterans Health Education Coordinator.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that processes be strengthened to ensure that acute care staff document stage for all patients with pressure ulcers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that processes be strengthened to ensure that acute care staff consistently document required pressure ulcer information and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Healthcare Inspection – Questionable Cardiac Interventions and Poor Management of Cardiovascular Care, Edward Hines, Jr. VA Hospital, Hines, Illinois
|
13-02053-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that cardiologists performing coronary interventions and surgeons performing cardiac surgery adhere to accepted standards of care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that adequate equipment is available in the operating room in accordance with VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that processes are strengthened to improve bed utilization.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that processes are strengthened to ensure contract oversight in accordance with VA requirements.
Combined Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico
|
14-00659-111

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that the PRC’s membership be revised to ensure that sufficient experienced senior physicians are regular members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently reported to the PRC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that the Surgical Work Group meet monthly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that all critical incidents are reported through the patient incident reporting process.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that the Blood Utilization Review Committee members from Surgery and Anesthesia Services consistently attend meetings and that the blood usage review process includes the results of proficiency testing.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that the local observation bed policy be revised to include all required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that EOC and Administrative Executive Board Committee minutes reflect deficiencies identified on the locked MH unit.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2014
We recommended that processes be strengthened to ensure that cabinets containing contrast agents in the radiology area are secured at all times and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that crash cart checks in the radiology area are documented daily and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that all MH unit staff and occasional MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA’s National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that panic alarm testing documentation includes police response times and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2014
We recommended that processes be strengthened to ensure that the medication list provided to the patient/caregiver at discharge is reconciled with the dosage and frequency ordered and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2014
We recommended that processes be strengthened to ensure that patients are provided with correct information on discharge instructions.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommended that processes be strengthened to ensure that patients’ post-hospitalization outpatient appointments are scheduled within the timeframe requested by the discharging physician.
Healthcare Inspection – Administrative Irregularities, Leadership Lapses, and Quality of Care Concerns, VA Central Iowa Health Care System, Des Moines, Iowa
|
13-02073-106

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated System Network Director ensure that the Chief of Staff appoints a director of the specific unit of the subject Service Line, who meets the qualification standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that selection of physicians who will be participating in medical educational activities is conducted within the standards of the Accreditation Council of Graduate Medical Education’s Residency Review Committee and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure the implementation of a standardized process for the management of cardiology consults, consistent with VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure processes be strengthened so that Focused Professional Practice Evaluations for licensed independent practitioners are consistently conducted as required, and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the Chief of Staff maintain a comprehensive list of staff that is authorized to perform out of Operating Room airway management in compliance with facility policy.
Combined Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana
|
14-00308-105

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that the Blood Utilization Review Committee include a clinical representative from Surgery Service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2015
We recommended that processes be strengthened to ensure that corrective actions are initiated and/or consistently followed to resolution when data analyses indicated problems or opportunities for improvement in the Performance Improvement, Medical Executive, and Executive Safety Committees.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that processes be strengthened to ensure that patient care areas and restrooms are clean and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that processes be strengthened to ensure that holes in the walls are repaired and that ongoing maintenance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that the annual staffing plan reassessment process ensures that unit 6E's and unit 9E's unit-based expert panels include all required members.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that Interprofessional Skin Integrity Committee minutes include data analysis.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Audit of VHA's Supportive Services for Veteran Families Program
|
13-01959-109

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2014
We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program implement a mechanism to inform grantees when updated area median income limits are published.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2014
We recommend the Under Secretary for Health ensures the Supportive Services for Veteran Families program grantees follow up to obtain the required Certificate of Release or Discharge from Active Duty (DD 214) when interim documents are used to determine program eligibility.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Loma Linda Healthcare System, Loma Linda, California
|
14-00232-110

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that managers ensure that PII is protected by securing laboratory specimens during transport from the Rancho Cucamonga CBOC to the VA Loma Linda Healthcare System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommend that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that CBOC/PCC 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: 8/22/2014
We recommended that CBOC/PCC RN Care Managers receive motivational interviewing training within 12 months of appointment to PACT.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Healthcare Inspection – Unexpected Patient Death in a Substance Abuse Residential Rehabilitation Treatment Program, Miami VA Healthcare System, Miami, Florida
|
13-03089-104

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that the camera surveillance system is repaired and maintained and that surveillance is conducted as required on the SARRTP unit.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that the SARRTP unit is appropriately staffed at all times, as required by VHA and local policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that SARRTP staff implement a consistent and comprehensive approach to check patients returning to the unit for contraband and document results clearly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2014
We recommended that the System Director ensure that SARRTP staff more aggressively monitor patients for illicit drug use, to include increasing the use of random UDS and adhering to local and VHA policy when patients leave the unit.
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