All Reports

Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida
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12-03075-52

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: 5/15/2013
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
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12-00580-50

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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
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12-02277-49

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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
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12-00581-27

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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 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
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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.
Community Based Outpatient Clinic Reviews Brooklyn (Chapel Street) and Sunnyside (Queens), NY; Franklin (Venango), PA
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11-03655-30

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that the Chapel Street CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that the Chapel Street CBOC clinicians document education of foot care to diabetic patients in CPRS.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that the Queens 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: 5/23/2013
We recommended that the Queens 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: 5/23/2013
We recommended that the Venango CBOC clinicians document assessment of therapeutic footwear and/or orthotics for diabetic patients with risk assessment Level 2 or 3.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/29/2013
We recommended that the security of PII on laboratory specimens is ensured when they are transported from the Chapel Street CBOC.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that patient privacy in the examination rooms is ensured at the Queens CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that the security of PII on laboratory specimens is ensured when they are transported from the Queens CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that Venango CBOC staff secure the view of PII on computer screens.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2013
We recommended that managers develop a local policy for MH and/or medical emergencies that reflects the current practice and capability at the Queens CBOC.
Combined Assessment Program Review of the VA Northern California Health Care System, Sacramento, California
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12-03074-29

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that processes be strengthened to ensure that IC Functional Committee meeting minutes include sufficient data analysis and planning for corrective actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that processes be strengthened to ensure that all food items are labeled with expiration dates, that patient nutritional products are routinely inspected to ensure they are within their expiration dates, and that hand hygiene products are readily available.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2013
We recommended that processes be strengthened to ensure that expired medications are removed and stored separately from medications available for administration.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2013
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are developed for all polytrauma outpatients who require them.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2013
We recommended that the facility monitor compliance with its polytrauma training requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that nursing managers monitor the staffing methodology that was approved in September 2012.
Combined Assessment Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan
|
12-02600-28

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that test strips are stored and glucometers are maintained in accordance with the manufacturers¿ recommendations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that staff make and document post-discharge telephone calls in accordance with local policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2013
We recommended that the locked acute MH unit have camera surveillance monitoring at all required locations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that the PR Committee is consistently notified when corrective actions are completed and that this notification is documented in the meeting minutes.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that the Medical Records Committee provides oversight and coordination of EHR quality reviews and that EHR quality reviews are consistently completed for all services, including Surgical Service.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2013
We recommended that processes be strengthened to ensure that aggregated data from resuscitation episodes is reported to the CPR Subcommittee monthly and documented in the meeting minutes.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that all required services be available to polytrauma outpatients and that minimum staffing levels be maintained.
Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania
|
12-01877-25

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: 4/5/2013
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that all discharged MH patients receive follow-up within 7 days of discharge and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the facility offer MH services at least one evening per week.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that patient care areas and fall mats are clean.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2012
We recommended that processes be strengthened to ensure that sensitive patient information displayed on computer screens is secured.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that final summary notes for ethics consults pertaining to active clinical cases are documented in the EHRs.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that glucometers are cleaned and maintained in accordance with the manufacturer's recommendations.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Audit of VA’s Office of Information Technology Strategic Human Capital Management
|
11-00324-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/12/2013
We recommended that the Assistant Secretary for Information Technology establish a strategic human capital plan development process that includes Office of Information Technology's senior management, managers, and employees along with appropriate stakeholders from across VA and its administrations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop and implement a strategic human capital plan that includes roles and responsibilities; human capital goals, objectives, and strategies; performance measures; and milestones as outlined in the Human Capital Assessment and Accountability Framework.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology's strategic human capital plan is aligned with VA's missions, goals, and objectives; and integrated into the Information Technology and VA Strategic Plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/12/2013
We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology has an adequate number of leadership and staff positions assigned to administer its strategic human capital program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop a leadership succession plan, including key actions and associated milestones for its implementation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology ensure that all information technology leadership and employee competency assessments and gap analyses are completed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop leadership and workforce development and hiring strategies for closing identified competency gaps.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/4/2013
We recommended that the Assistant Secretary for Information Technology maintain a current listing of contracts used by each OIT organizational element and the functions performed to identify areas where OIT uses contractors to address competency gaps.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology institute metrics and a process to measure the effectiveness of its strategies for evaluating and improving human capital management.
Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri
|
12-02188-15

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: 3/7/2013
We recommended that the holes in the walls be repaired and that processes be strengthened to ensure that patient care areas are clean.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2012
We recommended that the DRRTP have Class K fire extinguishers available in the kitchens used by residents.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that designated employees at the John Cochran dental clinic complete initial laser safety training and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that needle safety devices are available in the Jefferson Barracks dental clinic and that use of the devices be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that DRRTP and SA RRTP managers update the policies to safely manage medications and written procedures for contraband detection to include all VHA requirements and that compliance with the updated policies and procedures be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommended that processes be strengthened to ensure that monthly DRRTP and SA RRTP self-inspections are conducted and that documentation includes all required elements and corrective actions taken when deficiencies are identified.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommended that processes be strengthened to ensure that daily SA RRTP resident room inspections are thorough.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2012
We recommended that processes be strengthened to ensure that SA RRTP rooms occupied by female veterans are safe, private, and secure.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all non-physician employees complete the facility¿s required training program prior to assisting with or providing moderate sedation.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that informed consents are completed for all patients undergoing moderate sedation and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
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 least weekly during the first 30 days after discharge and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all patients discharged from inpatient MH receive follow-up MH appointments prior to being discharged.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2013
We recommended that the annual staffing plan reassessment process ensure that unit 6N's unit-based expert panel includes representatives from all nursing roles.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that unit 6N's nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all patients with positive TBI screening results have a comprehensive evaluation within the required timeframe.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are provided to polytrauma outpatients and/or the patients' families.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that staff in all testing areas are aware of the location of the current electronic glucose POCT manual.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that staff complete the action required in response to critical test results and document in the glucometer or EHR the name of the specific provider notified of the critical test results.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers or required by local policy.
Healthcare Inspection - Respiratory Care and Other Clinical Concerns, VA Northern Indiana Health Care System, Fort Wayne, IN
|
11-03462-17

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2013
We recommended that the facility Acting Director ensures that facility respiratory care policies are updated, including specific guidance and expectations for ordering oxygen therapy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2013
We recommended that the facility Acting Director ensures that peer review processes comply with VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2013
We recommended that the facility Acting Director implements procedures to complete an assessment of ABG usage.
Audit of VA’s Systems Interconnections with Research and University Affiliates
|
11-01823-294

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/15/2014
We recommend the Assistant Secretary for Information and Technology establish or update all Memoranda of Understanding and Interconnection Security Agreements needed to accurately reflect operational environments and require that research partners implement information security controls commensurate with VA's information security standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/17/2014
We recommend the Assistant Secretary for Information and Technology support the Under Secretary for Health by providing the information technology infrastructure needed to implement a centralized data governance and storage model to securely manage research information over the data life cycle.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/3/2014
We recommend the Assistant Secretary for Information and Technology direct Information Security Officers to partner with the Veterans Health Administration's Institutional Review Boards, research personnel, and research partners to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/15/2015
We recommend the Under Secretary for Health develop and implement a centralized data governance and storage model that ensures accurate inventory of all research data collected, data collection compliance with research protocols, and secure management of research information over the data life cycle.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommend the Under Secretary for Health require the Office of Research and Development to partner with Information Security Officers to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
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