All Reports

Healthcare Inspection – Laboratory Delays and Alleged Staff Training Issues, Memphis VA Medical Center, Memphis, Tennessee
|
13-02599-311

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2014
We recommended that the Facility Director ensure that processes be strengthened to ensure that laboratory turnaround times adhere to facility and VISN 9 expectations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2014
We recommended that the Facility Director ensure that policies and processes are put in place to establish consistent and appropriate methods for data collection and analysis of laboratory turnaround times.
Community Based Outpatient Clinic Reviews at the Fargo VA Health Care System, Fargo, ND
|
13-00026-317

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/12/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2014
We recommended that auditory privacy is maintained during the check-in process at the Bemidji and Fergus Falls CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Chief of OI&T implements required measures at the Bemidji and Fergus Falls CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that managers develop a local policy for MH emergencies that reflects the current risk, practice, and capability at the Bemidji CBOC.
Combined Assessment Program Review of the Amarillo VA Health Care System, Amarillo, Texas
|
13-02313-310

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that senior leaders routinely discuss the facility's Inpatient Evaluation Center data and ensure the discussions are documented in the minutes of a senior-level committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that results of completed FPPEs for newly hired licensed independent practitioners are reported to the MEC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that the local observation bed policy be revised to include how the service or the physician responsible for the patient is determined, that each admission must have a limited severity of illness, and assessment expectations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that the facility establish a policy that defines Special Care Committee responsibilities, including code episode reviews and data collection.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing, of peer reviews, and of inspections by government or private (peer) entities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that medications are secured at all times and only pharmaceutical items are stored in medication refrigerators and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that processes be strengthened to ensure that the PCCT includes an assigned administrative support person.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that advance directive screening is performed upon admission for all HPC inpatients.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that a Hospice/End of Life Care Plan is completed for all HPC inpatients.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2014
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections and/or daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that the facility establish ongoing staff pressure ulcer education requirements and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in December 2012.
Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut
|
13-01976-312

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that the data collected from resuscitation episodes are critically analyzed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a quality control policy for scanning.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC Committee minutes include results of EOC rounds, identify who is responsible for correcting environmental deficiencies, and track deficiencies to closure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that restrooms and showers on inpatient units are clean.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that public restrooms and elevators are clean, that public restrooms are free from environmental safety hazards, and that automatic door opening switches in all public restrooms are operational.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate actions to address the four identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be implemented to ensure that quarterly trend reports are provided timely to the facility Director and that trending and analysis of the data includes all elements required by VHA policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required non-pharmacy and pharmacy areas with CS are inspected monthly.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inspectors validate 2 transfers of CS from 1 storage area to another area and that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the PCCT includes a dedicated administrative support person and psychologist or other mental health provider.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document PU location, stage, risk scale score, and date acquired.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections for patients at risk for or with PUs and consistently revise prevention plans if the patients’ risk levels change.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the PU risk scale, how to conduct a complete skin assessment, and how to accurately document findings.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nurse managers reassess the target nursing hours per patient day for the medical intensive care unit to more accurately plan for staffing and evaluate the actual staffing provided.
Combined Assessment Program - Evaluation of Polytrauma Care in Veterans Health Administration Facilities
|
12-01702-303

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health ensures that VHA performs a detailed analysis of workload and resource use to determine whether there is continued need for the numbers of sites at the current levels and whether changes in the requirements for dedicated polytrauma resources are needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that Level IV sites performing comprehensive TBI evaluations have approved alternate plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently complete TBI evaluations within 30 days of positive screens and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that the case management process meets requirements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that staff caring for polytrauma patients have the documented competencies required for caring for polytrauma patients and that compliance is monitored.
Community Based Outpatient Clinic Reviews at VA Maryland Health Care System, Baltimore, Maryland
|
13-00026-306

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Combined Assessment Program Review of the Cheyenne VA Medical Center, Cheyenne, Wyoming
|
13-02312-304

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2014
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2014
We recommended that all required members participate in Transfusion Review/Lab Utilization Review Committee meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that the facility establish a policy for pressure ulcer prevention, establish an interprofessional pressure ulcer committee, and ensure that the interprofessional pressure ulcer committee reports program data to facility executive leadership.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a complete skin inspection and risk scale at discharge and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and/or risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that the facility establish patient/caregiver and staff pressure ulcer education requirements and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that the facility fully implement the nurse staffing methodology.
Inspection of VA Regional Office St. Paul, Minnesota
|
13-01550-286

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2014
We recommend the St. Paul VA Regional Office Director conduct a review of the 299 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2014
We recommend the St. Paul VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of that training.
Inspection of VA Regional Office Togus, Maine
|
13-02257-294

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2014
We recommend the Togus VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examinations to obtain the evidence required to support traumatic brain injury evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2014
We recommend the Togus VA Regional Office Director develop and implement a plan to ensure staff completely and timely address all required elements of Systematic Analyses of Operations.
Healthcare Inspection - Gastroenterology Consult Delays, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
|
12-04631-313

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommend that, in accordance with the Administrative Investigation Board conclusions and recommendations, Veterans Integrated Service Network leaders take appropriate action in relationship to leadership deficits contributing to the gastroenterology consult backlog.
Audit of VBA's Pension Payments
|
12-00181-299

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/8/2017
We recommended the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements procedures that ensure continued veteran and beneficiary eligibility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/4/2013
We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements a plan to reduce the amount of underpayments and overpayments due to changes in income and dependency.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/4/2014
We recommend the Under Secretary for Benefits implement the use of the enhanced interagency exchange agreements with the Internal Revenue Service and Social Security Administration to reduce delays in verifying veteran and beneficiary reported income.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/22/2017
We recommended the Under Secretary for Benefits establish a matching program with Medicaid to automatically identify veterans and beneficiaries that require nursing home adjustments.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/4/2014
We recommend the Under Secretary for Benefits ensure the Pension Management Centers clearly outline processing priorities in their workload management plans.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/4/2014
We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements its plan to revise triage procedures and establish processing lanes to ensure prompt screening and routing of claims.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/4/2014
We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service corrects the duplicate records identified in this audit.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/3/2014
We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service requests an additional data test be added to their current series of data tests that would identify claimant records with similar or same names under the same file number.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 502,000,000.00
Healthcare Inspection – Alleged Sterile Processing Service Deficiencies, VA Puget Sound Health Care System, Seattle, Washington
|
13-01351-296

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2014
We recommended that the System Director ensure that Sterile Processing Service has a process in place to identify single-use devices and mitigate the risk of single-use devices being resterilized.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2014
We recommended that the System Director ensure that processes be strengthened to ensure that Sterile Processing Service staff competency records are well organized and that managers are able to readily determine the current competence of each person on each task.
Inspection of VA Regional Office Muskogee, Oklahoma
|
12-04326-275

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2014
We recommend the Muskogee VA Regional Office Director conduct a review of the 304 temporary 100 percent disability evaluations remaining from our inspection universe.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2014
We recommend the Muskogee VA Regional Office Director provide refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of the training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2014
We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure accurate second-signature reviews of traumatic brain injury claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2013
We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure Rating Veterans Service Representatives correctly address Gulf War veterans' entitlement to mental health treatment as required.
Community Based Outpatient Clinic Reviews at Chillicothe VA Medical Center, Chillicothe, OH
|
13-00026-302

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2014
We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2014
We recommended that a written inventory of hazardous materials is maintained.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that all identified EOC deficiencies are tracked, trended, and corrected.
Inspection of VA Regional Office Albuquerque, New Mexico
|
13-00993-274

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/10/2014
We recommend the Albuquerque VA Regional Office Director conduct a review of the 190 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/10/2014
We recommend the Albuquerque VA Regional Office Director conduct refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2013
We recommend the Albuquerque VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to obtain the evidence required to support traumatic brain injury evaluations.
Inspection of VA Regional Office Newark, New Jersey
|
13-01625-273

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/16/2014
We recommend the Newark VA Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/30/2014
We recommend the Newark VA Regional Office Director develop and implement a plan to review the 149 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2014
We recommend the Newark VA Regional Office Director develop and implement a plan to ensure effective second-signature reviews of traumatic brain injury claims decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/16/2014
We recommend the Newark VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers within the VA Regional Office's jurisdiction.
Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California
|
13-01975-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that floors in patient care areas are clean and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive annual competency assessments.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that RME standard operating procedures are consistent with manufacturers’ instructions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that bi-weekly inventories of automated dispensing machines are consistently conducted and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that end of shift counts for non-automated dispensing units are completed daily and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the inspection checklist be amended to include all required items and that processes be strengthened to ensure that inspectors perform drug destruction and audit trail verification and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated social worker and a dedicated psychologist or other MH provider.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff consistently document location, stage, risk scale score, and/or date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the dietary screening and assessment of patients with pressure ulcers is consistent with facility policy and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility fully implement the nurse staffing methodology.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Audit of Foreclosed Property Management Contractor Oversight
|
12-01899-238

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2013
We recommended the Under Secretary for Benefits ensure the Veterans Benefits Administration's foreclosed property management contractor provides vendor invoices to substantiate expenses claimed by the contractor prior to reimbursement by Loan Guaranty Service.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2013
We recommended the Under Secretary for Benefits determine whether it is cost effective to initiate recovery of improper payments identified in our audit.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/9/2014
We recommended the Under Secretary for Benefits develop policies that require Loan Guaranty Service to report maintenance exceptions to its foreclosed property management contractor when identified and follow up to ensure correction.
Combined Assessment Program Review of the Fargo VA Health Care System, Fargo, North Dakota
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13-01973-288

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: 1/10/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired LIPs are consistently initiated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that the results of non-VA purchased care during which diagnostic tests are performed are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2014
We recommended that the facility develop instructions for inspections of automated dispensing machines and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections and annually and that all CS inspectors receive annual updates and refresher training and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled and that a hard copy order for at least 2 randomly selected dispensing activities is verified and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that inspectors consistently verify the number of prescription pads and that 72-hour inventories of the main vault are consistently performed and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that physical counts of all pharmacy drugs are completed during the 1st month of the quarter and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that inspectors verify hard copy prescriptions for 10 percent of the schedule II drugs dispensed in the outpatient pharmacy and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that drugs held for destruction are consistently compared with the Destruction File Holding Report, that inspectors consistently verify drug destructions are completed at least quarterly, and that inspectors ensure audit trails for destruction of 10 randomly selected drugs are consistently verified and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2014
We recommended that processes be strengthened to ensure that inspector competencies are documented and that inspectors date and initial inspection documents at the time of the inspection and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and the date the pressure ulcer was acquired for all patients with pressure ulcers and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that documentation of construction site inspections includes time of inspections, type of corrective action for identified deficiencies, and date and time of corrective actions.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in ICC minutes.
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