All Reports

Audit of VHA's Physician Staffing Levels for Specialty Care Services
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11-01827-36

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health approve a plan by the end of FY 2013 that ensures all specialty care services have productivity standards within 3 years.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health establish productivity standards for at least five specialty care services by the end of FY 2013 and ensure medical facility personnel compare physician workload against these standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health provide medical facility directors with more specific guidance on how to develop staffing plans and ensure medical facility management review them at least annually to ensure optimal efficiency.
Healthcare Inspection – Pharmacy and Quality of Care Issues, VA Hudson Valley Health Care System, Castle Point, New York
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12-02352-72

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2013
We recommended that the Director ensure that the recommendations included in the Administrative Investigation Board report are complied with.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2013
We recommended that the Director ensure that all pharmacy staff be provided ethics training to ensure that employees report unethical behavior without fear of repercussion.
Healthcare Inspection – Alleged Patient Safety Deficiencies in the Community Living Center, Canandaigua VA Medical Center, Canandaigua, New York
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12-03543-73

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that the facility Director implement procedures to ensure that unit-level reviews of patient falls are patient-specific and address the specific circumstances surrounding the falls.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that the facility Director implement procedures to ensure that fall prevention interventions are documented in patient care plans.
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas
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12-03076-65

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2013
We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2013
We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2013
We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2013
We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.
Review of Allegations at VA Medical Center, Providence, Rhode Island
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10-01937-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director establish controls to ensure the Providence VA Medical Center accurately certifies its Annual Certification of Accounting Records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director terminates this contract, and if the services are still needed, recruits and hires under appropriate civil service procedures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director require the Providence VA Medical Center Director to implement controls ensuring all fund obligations are accompanied by supporting documentation to justify the obligation as required by law.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2012
We recommended the Veterans Integrated Service Network 1 Director ensure service contracts are awarded based on adequate competition or, if competition is not feasible, are supported by limited or sole-source justifications as required by Federal Acquisition Regulation.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director establishes controls to ensure appropriated funds are used only for the intended purpose of the appropriation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2013
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the Designated Education Officer to obtain and oversee annual rate changes for disbursing agreements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2013
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director charges the Chief of Facilities Management Service 25 days of annual leave because his absence was not supported by an approved written justification.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2013
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director institutes a control that ensures at the point timecards are certified appropriate documentation in support of approved excused absences is in place.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2012
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the property owner to make necessary repairs to alleviate future water leaks and damage, and if not repaired, moves employees in the affected areas to a more suitable workspace.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,444.00
Review of VHA's Minor Construction Program
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12-03346-69

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
Combined Assessment Program Review of the VA Maine Healthcare System,Augusta, Maine
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12-03741-61

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2013
We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Audit of Vocational Rehabilitation and Employment Program's Self-Employment Services at Eastern and Central Area Offices
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11-00317-37

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2014
We recommended the Under Secretary for Benefits implement procedures to improve the accuracy of data in Corporate WINRS.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/15/2013
We recommended the Under Secretary for Benefits perform a data integrity review comparing Corporate WINRS to active self-employment Counseling/Evaluation/Rehabilitation files and take corrective action as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2015
We recommended the Under Secretary for Benefits develop and implement performance measures that evaluate the success of self-employment services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2012
We recommended the Under Secretary for Benefits provide training to Eastern and Central area Vocational Rehabilitation and Employment staff to ensure they understand the criteria used to determine rehabilitation status for participants in self-employment services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/2/2013
We recommended the Under Secretary for Benefits include guidance in Veterans Benefits Administration's Manual M28 to clarify when it is appropriate to provide services for veterans with an established business under a self-employment plan.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2012
We recommended the Under Secretary for Benefits revise Veterans Benefits Administration's Manual M28, Part IV, to ensure Veterans Benefits Administration's guidance aligns with Title 38, Code of Federal Regulations, for approval of self-employment plans.
Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina
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12-03071-53

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect sufficient analysis and follow-up of EOC inspection findings and track identified deficiencies to resolution.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
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: 7/9/2013
We recommended that processes be strengthened to ensure that the hazardous materials inventory is current.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that hazard assessments are completed in the dental laboratory and the ED and that emergency eyewash stations are added if needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that required SCI outpatient clinic staff are assigned and receive SCI-specific training and that compliance with training requirements be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe and that the facility evaluate the five cases to determine what further actions may be warranted.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that discharge summaries include discharge medications.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2013
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that the designated clinical service respond to consultation requests for TBI comprehensive evaluations within the required timeframe.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2014
We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation within the required timeframe.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that the facility comply with polytrauma training requirements.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that senior managers discuss the data from the Inpatient Evaluation Center at a senior-level committee and document the discussion in the committee's meeting minutes.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that FPPEs are completed for all newly hired licensed independent practitioners and that results are consistently reported to the Medical Executive Committee.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that clinical service EHR quality reviews are completed and results forwarded to the EHR Committee and that the EHR Committee provides consistent oversight, coordination, and evaluation of EHR quality reviews.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that the copy and paste functions are monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2014
We recommended that processes be strengthened to ensure that staff complete all actions required in response to critical test results.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that providers sign all pre-sedation assessments completed by nursing staff.
Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas
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12-03073-57

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that FPPEs are initiated for all newly hired licensed independent practitioners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that all completed ethics consultations are documented in ECWeb.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that patients are appropriately monitored during moderate sedation
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that clinical staff in areas where moderate sedation is performed are aware of local policy requirements for identifying correct surgical and invasive procedure sites when the sites cannot be marked.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that providers document care hand-off in accordance with local policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2013
We recommended that processes be strengthened to ensure that interdisciplinary teams develop treatment plans for all polytrauma outpatients who need them and that the plans contain all required elements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2013
We recommended that processes be strengthened to ensure that service directors develop program-specific competencies and training for all staff assigned to the Polytrauma-TBI Program.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that SCI outpatient clinic employees receive population-specific training.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that the facility implement the mandated staffing methodology for nursing personnel.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2013
We recommended that processes be strengthened to ensure that all POCT instruments are inspected by biomedical engineering prior to initial use.
Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida
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12-03075-52

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that EOC-Safety and IC Committee minutes reflect sufficient data analysis, actions implemented, and tracking of items to closure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that a comprehensive EOC inspection of the ED be conducted and that appropriate actions be taken to correct IC and safety deficiencies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that emergency exits are not obstructed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that MSDS inventory lists and hazardous materials information binders are current and that staff are trained on accessing the electronic MSDS materials.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and SCI outpatient clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that medications, chemicals, solutions, and cleaning carts are properly secured.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections and daily room inspections are conducted and that inspection reports contain adequate documentation of follow-up.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that all informed consents are completed appropriately and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo monthly urine drug screenings.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that processes be strengthened to ensure that discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated timely and documented and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2013
We recommended that processes be strengthened to ensure that all patients are notified of biopsy results within the required timeframe and that clinicians document notification in the EHR.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinician notification of critical test results is documented on the required template.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that local policies related to FSBG monitoring and patient management be updated to reflect actual practice.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that processes be strengthened to ensure that all services complete EHR quality reviews.
Healthcare Inspection - Inpatient and Residential Programs for Female Veterans with Mental Health Conditions Related to Military Sexual Trauma
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12-03399-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2013
We recommended that the Under Secretary for Health review existing VHA policy pertaining to authorization of travel for veterans seeking MST related MH treatment at specialized inpatient/residential programs outside of the facilities where they are enrolled.
Combined Assessment Program Review of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
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12-03072-48

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2012
We recommended that processes be strengthened to ensure that at least two preventive ethics improvement cycles are completed each FY.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that processes be strengthened to ensure that the EHR committee provides consistent oversight and coordination of EHR quality reviews and that quality reviews are completed, analyzed, and trended for all services, including long-term care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that a rehabilitation nurse be available for the polytrauma program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo urine drug screenings with the frequency required by local policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2013
We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2013
We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up evaluations at the required intervals and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that processes be strengthened to ensure that employees who perform glucose POCT have their competency assessed at the required intervals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2013
We recommended that processes be strengthened to ensure that staff complete and document the actions required in response to critical test results.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommended that processes be strengthened to ensure that Clinical Engineering staff inspect, approve, and label glucose meters in accordance with local policy.
Community Based Outpatient Clinic Reviews Franklin, WV; Stephens City, VA; Greenbelt, MD; Southeast Washington, DC
|
12-00580-50

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2013
We recommended that the Franklin and Stephens City CBOC clinicians document education of foot care to diabetic patients in CPRS.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2013
We recommended that the Franklin and Stephens City CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that the Southeast Washington CBOC clinicians document complete foot screenings for diabetic patients in CPRS.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommended that the Greenbelt and Southeast Washington CBOC clinicians document education of foot care to diabetic patients in CPRS.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2013
We recommended that the Greenbelt and Southeast Washington CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that the Stephens City CBOC establish a process to ensure that patients with normal mammograms are notified of results within the allotted timeframe and that notification is documented in the medical record.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the managers at the Greenbelt and Southeast Washington CBOCs ensure that all mammogram results are documented using the BI-RADS code categories.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the Women's Health Program Manager at the Washington DC VAMC ensure that the Greenbelt and Southeast Washington CBOC fee-basis mammography results are received and scanned into CPRS.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the Executive Committee of the Medical Staff, Credentialing Committee, grant privileges consistent with the services provided at the Franklin and Stephens City CBOCs.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the process is strengthened to ensure that privileges granted to psychologists are provider specific and consistent with the setting in which the services are provided at the Greenbelt CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2013
We recommended that privacy is maintained at all times during a patient physical examination at the Franklin CBOC.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2013
We recommended that signage is installed at the Franklin CBOC to clearly identify the location of fire extinguishers.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that fire extinguishers are inspected at the Franklin CBOC and that maintenance and inspection dates are documented in accordance with NFPA Life Safety Code.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2013
We recommended that biohazardous waste containers are stored appropriately and that clean and dirty items are stored in separate locations at the Franklin CBOC.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2013
We recommended that the electrical closet is free of hazardous chemicals at the Stephens City CBOC.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that fire drills and fire safety inspections are conducted annually at the Greenbelt CBOC.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2013
We recommended that the Facility Director determines, with the assistance of the Regional Counsel, the extent and collectability of the overpayments at the Franklin CBOC.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2013
We recommended that the Facility Director ensures that the contractor provide the invoice in the prescribed format at the Franklin CBOC.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2013
We recommended that the Facility Director ensures that all the performance-reporting provisions of the contract are completed and monitored at the Franklin CBOC.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the Facility Director considers adding controls in the invoice validation process, such as preparing a monthly billable roster with VA data at the Franklin CBOC.
Healthcare Inspection – Alleged Resident Abuse and Abuse Reporting Irregularities at the Pueblo Community Living Center, VA Eastern Colorado Healthcare System, Denver, Colorado
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12-03858-46

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the system Director ensure all Associate Chiefs of Nursing and Community Living Center staff receive retraining on the requirements for reporting allegations of abuse.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the system Director ensures procedures to report, log, track, trend, and analyze injuries of unknown origin at the Community Living Center are developed.
Healthcare Inspection - Clinical and Administrative Allegations Involving Surgical Service, Carl Vinson VA Medical Center, Dublin, GA
|
12-02277-49

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2013
We recommended that the facility Director ensure that provider reprivileging processes be conducted in accordance with VHA guidelines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2013
We recommended that the facility Director ensure the OOPRC collects and analyzes aggregated surgical complication data to identify trends and patterns, and takes appropriate corrective actions when indicated.
Community Based Outpatient Clinic Reviews Minden (Carson Valley), NV; Auburn (Sierra Foothills), Chula Vista, and Escondido, CA
|
12-00581-27

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the Facility Director ensure that foot screening and patient referral guidelines are established in accordance with VHA policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the Sierra Foothills CBOC clinicians document foot care education to diabetic patients in CPRS.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the Carson Valley CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document that therapeutic footwear or orthotics is prescribed to diabetic patients identified at high risk for extremity ulcers and amputation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that the Chula Vista and Escondido CBOC clinicians document foot care education to diabetic patients in CPRS.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2014
We recommended that the Chula Vista and Escondido CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that the Chula Vista and Escondido CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2013
We recommended that the Carson Valley CBOC establish a process to ensure that patients with normal mammogram results are notified of results within the allotted timeframe and that notification is documented in the medical record.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2013
We recommended that the Women¿s Health Liaison at the Chula Vista CBOC attend the Women¿s Health Committee meetings and routinely collaborate with the Women Veterans Program Manager.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that the privileges granted to providers are consistent with the services provided at the Chula Vista CBOC and that privileges are setting specific at Chula Vista and Escondido CBOCs.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2013
We recommended that OPPE data be maintained in all providers¿ profiles at the Escondido CBOC.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that managers collect and analyze data for hand hygiene at the Carson Valley and Sierra Foothills CBOCs.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2014
We recommended that the VISN and Facility Directors ensure that the deficiencies at the Escondido CBOC are addressed and corrected to ensure compliance with the ADA requirements.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2013
We recommended that the Chula Vista CBOC implement a process to ensure that patient PII is protected and secured.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2013
We recommended that the Network Contracting Office, in conjunction with VISN and Facility Directors, award a competitive long-term contract and to ensure that future acquisitions allow for adequate planning time to avoid the need for ICA.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2013
We recommended that the Service Area Office (SAO) West Director and MSO Directors ensure that the use of ICA complies with VA directives.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that the SAO West Director and Network Contract Manager ensure appropriate oversight and enforcement of VA directives before an ICA is approved and a contract is signed.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that the SAO West Director and Network Contract Manager ensure that contracting officers are held accountable for noncompliance with VA directives.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2013
We recommended that the Facility Director and Network Contract Manager confer with Regional Counsel to determine the amount and collectability of all overpayments.
Healthcare Inspection – Alleged Clinical and Administrative Issues, VA Loma Linda Healthcare System, Loma Linda, CA
|
12-01758-40

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2012
We recommended that the Facility Director ensure that MH patients receive timely care, including initial evaluations within 24 hours and comprehensive evaluations within 14 days.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2013
We recommended that the Facility Director establish a MH Executive Council as required by VHA.
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