All Reports

Review of Alleged Mismanagement of VBA's Eastern Area Fiduciary Hub
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13-03018-159

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/28/2014
We recommended the Under Secretary for Benefits require the Eastern Area Fiduciary Hub to implement controls to monitor misuse determinations to ensure reviews meet timeliness standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/1/2015
We recommended the Under Secretary for Benefits require the Director of Pension and Fiduciary Service to implement controls to monitor negligence reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/1/2015
We recommended the Under Secretary for Benefits implement controls to ensure the reissuance of misused funds to beneficiaries and repayment from former fiduciaries occurs timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2014
We recommended the Under Secretary for Benefits require the Director of Pension and Fiduciary Services to conduct a negligence review of the 12 identified cases of misuse of beneficiary funds and determine if misused funds are required to be reissued to affected beneficiaries.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2018
We recommended the Under Secretary for Benefits ensures the Eastern Area Fiduciary Hub implements a plan to expedite completion of their backlog of field examinations to meet performance standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/15/2015
We recommended the Under Secretary for Benefits require the Director of the Indianapolis VA Regional Office to implement a plan to ensure the Eastern Area Fiduciary Hub eliminates its backlog of Fiduciary Program mail during FY 2014.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 944,000.00
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System
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14-02603-178

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No. 1
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary take immediate action to review and provide appropriate health care to the 1,700 veterans we identified as not being on any existing wait list.
No. 2
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary review all existing wait lists at the Phoenix Health Care System to identify veterans who may be at greatest risk because of a delay in the delivery of health care (for example, those veterans who would be new patients to a specialty clinic) and provide the appropriate medical care.
No. 3
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary initiate a nationwide review of veterans on wait lists to ensure that veterans are seen in an appropriate time, given their clinical condition.
No. 4
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary direct the Health Eligibility Center to run a nationwide New Enrollee Appointment Request report by facility of all newly enrolled veterans and direct facility leadership to ensure all veterans have received appropriate care or are shown on the facility's electronic waiting list.
Combined Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan
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14-00686-166

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2014
We recommended that nursing managers fully implement the plan approved in March 2014.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2014
We recommended that the annual staffing plan reassessment process ensures that the acute care unit-based expert panel includes all required members.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document the risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2017
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that wound care specialist consults are initiated and completed for all patients with pressure ulcers and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to residents' care plans and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015
We recommended that processes be strengthened to ensure that staff document residents' progress toward restorative nursing goals and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that processes be strengthened to ensure that staff document residents' restorative progress bi-weekly and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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14-00242-160

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2014
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2014
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that staff provide medication counseling/education as required.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Aleda E. Lutz VA Medical Center, Saginaw, Michigan
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14-00231-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the sink faucet control in the handicap accessible restroom at the Alpena CBOC meets Americans with Disabilities Act Guidelines and is accessible during regular clinic hours.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Alpena and Bad Axe CBOCs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Bad Axe CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility includes staff at the Alpena and Bad Axe CBOCs in required education, training, planning, and participation in annual disaster exercise.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Canandaigua VA Medical Center, Canandaigua, New York
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14-00244-147

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Rochester CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that all identified EOC deficiencies at the Rochester CBOC are tracked by the parent facility EOC Committee until resolution.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screens and drinking levels above NIAAA limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Review of Alleged Unauthorized Commitments Within VA
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13-00991-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/24/2015
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, review FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 10/22/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, establish policies and procedures to perform recurring reviews of purchase card transactions above the micro-purchase threshold to identify transactions made by cardholders without appropriate warrant authority.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 5/21/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, revise policies and procedures to verify that purchase card spending limits do not exceed warrant authority limits before issuing individuals purchase cards with spending limits above the micro-purchase threshold.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 5/21/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, require recurring unauthorized commitment training for purchase cardholders and their approving officials.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/12/2015
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, ensure the Management Quality Assurance Service follow-up on the status of ratification of identified unauthorized commitments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/7/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, direct Heads of Contracting Activities to perform individual ratification actions for unauthorized commitments identified by the Executive in Charge, Office of Management and Chief Financial Officer’s review of FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/16/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, create and maintain an accurate database of warranted VA contracting officers that includes warrant effective and expiration dates, and specific warrant authority limitations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/26/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, establish policies and procedures requiring Heads of Contracting Activities to complete ratification actions within a specified time period after the identification of unauthorized commitments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/26/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, limit institutional ratifications by ensuring every unauthorized commitment meets the ratification review requirements.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 85,600,000.00
Combined Assessment Program Review of the Wilmington VA Medical Center, Wilmington, Delaware
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13-04243-151

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the facility establish a policy for scanning health records and that compliance with the newly established policy be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the dialysis patient care area have an emergency eyewash station.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that the dialysis unit's chemical storage room is locked when unattended and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the clinical laboratory urinalysis section ceiling leak be repaired and that ceiling tiles in the clinical laboratory urinalysis section and blood bank and in the ambulatory surgery medication room be replaced.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the facility establish a policy addressing radiation equipment inspection, testing, and maintenance and fluoroscopy quality control and that compliance with the newly established policy be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that processes be strengthened to ensure that designated x-ray and fluoroscopy employees have radiation exposure monitoring completed annually and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that signs be posted in waiting and procedure rooms within radiology asking female patients to notify staff if they may be pregnant.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2015
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that processes be strengthened to ensure that patients/caregivers are provided medication lists at discharge and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that patients/caregivers are provided with discharge instructions and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that nursing managers monitor the staffing methodology that was implemented in August 2013.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that nurse managers reassess the target nursing hours per patient day for unit 4 East to more accurately plan for staffing and evaluate the actual staffing provided.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that the facility establish an interprofessional pressure ulcer committee.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that patient care areas are clean, that clean and dirty items are stored separately, and that medications are secured at all times and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2016
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify restorative nursing interventions as needed, and document the modifications and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for resident transfers.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that staff do not provide medical treatment to residents during meals in the common dining area.
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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14-00687-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the Surgical Work Group meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the facility implement their plan to track OPPEs and present them to the Professional Standards Board within the timeframe required by local policy and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that all MSIT members and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response time.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the locked MH units' seclusion room floors have a cushioned surface.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2015
We recommended that nursing managers monitor the staffing methodology implemented in October 2013.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that inspection documentation includes the time of the inspection and the time when corrective actions occurred.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are consistently conducted and documented in Infection Control Committee minutes.
Audit of the Quick Start Program
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12-00177-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits establish Veterans Service Network Operations Report capabilities to track claims from the date the Veterans Benefits Administration receives and establishes active servicemembers’ claims to the date of Servicemembers’ discharge from military service.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits track and report claims-processing time prior to Servicemembers’ discharge in timeliness performance results for the Quick Start Program or its successor.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits conduct recurring evaluations that identify needed staffing adjustments to ensure sufficient staff are allocated to accomplish the timeliness targets of the Quick Start Program or its successor.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits require Consolidated Processing Site and intake site claims assistants staff obtain periodic training on identifying and processing claims submitted through the Quick Start Program or its successor.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits modify Systematic Technical Accuracy Reviews to include a systematic review of claims processed through the Quick Start Program or its successor.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to analyze trends of systemic issues identified during Quality Review Team and Systematic Technical Accuracy Review evaluations of claims processed through the Quick Start Program or its successor.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to provide staff recurring training on systemic issues identified during trend analyses of Quality Review Team and Systematic Technical Accuracy Review results.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits revise policies and procedures to clarify that evidence must establish a nexus linking veterans’ claimed conditions to military service regardless of diagnosis proximity to discharge.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits require Consolidated Processing Site managers to ensure staff adhere to Veterans Benefits Administration policies related to service connection while processing claims received through the Quick Start Program or its successor.
Combined Assessment Program Review of the VA Montana Health Care System, Fort Harrison, Montana
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14-00685-156

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that the MEC document its discussion of unusual findings or patterns from PRC quarterly summary reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that the facility have a Surgical Work Group that meets monthly, includes the COS as a member, and documents its review of National Surgical Office reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that clinicians provide discharge instructions on all aftercare needs to patients and/or caregivers and document this in the EHR and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
Interim Report - VBA's Efforts to Effectively Obtain Service Treatment Records and Official Military Personnel Files
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14-00657-144

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/12/2014
We recommend the Under Secretary for Benefits identify and implement options to help alleviate the file storage issues at the regional office in St. Petersburg, FL.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2014
We recommend the Under Secretary for Benefits ensure mailroom personnel date stamp service treatment record files and copies of official military personnel files on the day they are received at the regional office in St. Petersburg, FL.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2014
We recommend the Under Secretary for Benefits identify and implement options to improve timeliness of evidence mail processing at the regional office in St. Petersburg, FL.
Audit of VHA's Mobile Medical Units
|
13-03213-152

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health withhold funding for new mobile medical units until a comprehensive assessment is conducted to assess factors, such as the current composition of the mobile medical unit fleet, services provided, operational days and costs, and the effect on rural veterans’ access to health care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health assign responsibility for developing mobile medical unit policies, objectives, and strategy, and for providing program oversight.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health assign responsibility for maintaining operational data on mobile medical units to ensure mobile medical unit resources can be used as part of VHA’s emergency preparedness plan.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended the Under Secretary for Health publish necessary policy and guidance to provide for effective and efficient mobile medical unit operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health implement a mechanism to ensure that mobile medical unit-specific operations and financial data, such as patient workload, services provided, and costs, are collected in the Veterans Health Administration’s Decision Support System.
Healthcare Inspection - VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid Therapy
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14-00895-163

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that the Under Secretary for Health ensure that the practice of prescribing acetaminophen is in compliance with acceptable standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
We recommended that the Under Secretary for Health ensure that VA's practice of routine and random urine drug tests prior to initiating and during take-home opioid therapy to confirm the appropriate use of opioids is in alignment with acceptable standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that follow-up evaluations of patients on take-home opioids are performed timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that opioid patients with active (not in remission) substance use receive treatment for substance use concurrently with urine drug tests.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that VA's practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with acceptable standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2015
We recommended that the Under Secretary for Health ensure that medication reconciliation is performed to prevent adverse drug interactions.
Combined Assessment Program Review of the Canandaigua VA Medical Center, Canandaigua, New York
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14-00688-162

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that EOC Work Group minutes reflect that actions are taken in response to identified deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the facility establish a policy for the safe use of fluoroscopic equipment and that compliance with the newly established policy be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2014
We recommended that processes be strengthened to ensure that all designated x-ray/fluoroscopy employees receive annual fluoroscopy safety training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2015
We recommended that processes be strengthened to ensure that restorative nursing staff consistently document weekly and monthly notes according to local policy and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2015
We recommended that processes be strengthened to ensure that providers are notified of critical laboratory and abnormal radiology test results/values within the expected timeframe and that notification is documented in the EHRs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the EHRs.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at James E. Van Zandt VA Medical Center, Altoona, Pennsylvania
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14-00236-153

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2014
We recommended that fire drills are performed every 12 months at the Johnstown CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2014
We recommended that medications are secured and only accessible by those individuals who either dispense or administer medications at the State College CBOC and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2014
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Johnstown CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2013
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13-00054-148

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that completed improvement actions related to protected peer review are reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facility observation bed processes are guided by comprehensive policies and that usage is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that reviews of inpatients’ continuing stays are consistently completed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ scanning processes are guided by comprehensive policies, that medical information is properly scanned into patients’ electronic health records, and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for thorough review of individual resuscitation episodes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
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