All Reports

Healthcare Inspection - Alleged Patient Rights, Quality of Care, and Other Issues, VA Puget Sound Health Care System, Seattle, Washington
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13-02235-277

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2014
We recommended the System Director ensure the Women Veterans Program Manager provides chaperone policy education to all system primary care clinics and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2014
We recommended the System Director ensure all staff are informed about the VHA requirement to report allegations of patient abuse and educated on the processes for reporting the alleged abuse.
Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming
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13-01671-262

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2014
We recommended that ECC membership includes all required disciplines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2014
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that processes be strengthened to ensure that the results of non-VA purchased care are consistently scanned into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that processes be strengthened to ensure that results of compliance with RME SOPs are reported to the RME Management Committee and the MEB.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive initial RME training and annual competency assessments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that processes be strengthened to ensure that manufacturers’ instructions are available for all RME items, that RME is reprocessed at the specified temperature, and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2014
We recommended that processes be strengthened to ensure that SPS sterile storage area temperature and humidity levels are consistently monitored and maintained within acceptable levels.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that facility policy be amended to include the requirement that CS inspectors receive annual updates regarding problematic issues identified through external survey findings and other quality control measures and that processes be strengthened to ensure that CS inspectors receive annual updates.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that the facility develop instructions for inspections of automated dispensing machines and that processes be strengthened to ensure that monthly findings summaries are provided to the facility Director and that quarterly trend reports clearly summarize discrepancies and problematic trends and identify potential areas for improvement.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2014
We recommended that processes be strengthened to ensure that CS inspectors’ appointments state the end date of their term and that CS inspectors’ terms do not exceed 3 years.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS are conducted in accordance with VHA requirements and include all required elements and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2014
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2014
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)
Closure Date: 4/16/2014
We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2014
We recommended that processes be strengthened to ensure that HPC inpatients’ pain is consistently assessed whenever vital signs are obtained and results documented in EHRs and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2014
We recommended that processes be strengthened to ensure that HPC inpatients’ pain assessments are documented in EHRs using approved note titles and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2014
We recommended that the interprofessional pressure ulcer committee includes a certified wound care specialist.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer location and stage and perform and document all required daily activities/inspections for patients with pressure ulcers and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document skin inspections and risk scales at discharge and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to discharge and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients and/or their caregivers and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2014
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.
Audit of Non-Purchase Card Micro-Purchases
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12-01860-237

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2014
We recommended the Under Secretary for Health collaborate with the VA Office of Management to establish policies and procedures to regularly identify and evaluate the universe of micro-purchases and non-purchase card micro-purchases to monitor the level of Veterans Health Administration use of purchase cards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2014
We recommended the Under Secretary for Health establish annual and long-term strategic goals to increase the percentage of VA medical facility micro-purchases made with purchase cards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2014
We recommended the Under Secretary for Health implement mechanisms to ensure purchasers and approvers adequately consider purchase card use for micro-purchases.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2014
We recommended the Under Secretary for Health modify policies and procedures requiring Veterans Integrated Service Networks to perform oversight of non-purchase card micro-purchases that identifies opportunities for increased use of purchase cards.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 120,000,000.00
Inspection of VA Regional Office Milwaukee, Wisconsin
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13-01445-271

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Combined Assessment Program Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma
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13-01670-269

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2014
We recommended that processes be strengthened to ensure that VA Police conduct annual physical security surveys of the pharmacy areas and that any identified deficiencies be corrected.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2014
We recommended that processes be strengthened to ensure that the PCCT includes an administrative support person and a dedicated psychologist or other MH professional.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2014
We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that the facility pressure ulcer policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer was acquired 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: 4/16/2014
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in December 2012.
Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri
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13-01675-266

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that processes be strengthened to ensure that the PCCT includes a 0.25 full-time employee equivalent psychologist or other mental health provider.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon discharge and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, assessments for change in condition, and/or revisions to prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
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13-00899-261

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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 FPPEs for newly hired LIPs are consistently initiated and that results are consistently reported to the MEC.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patient care areas and furnishings are clean and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inpatient rooms and ED medical equipment are consistently terminally cleaned and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that OR employees who perform IUS receive initial training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that 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 all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 8
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 nursing representative.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all HPC staff and other clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 10
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 a skin inspection and risk scale prior to discharge and that compliance be monitored.
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 accurately document PU location, stage, risk scale score, and data acquired 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 acute care staff perform and document daily skin inspections and risk scales for patients at risk for or with PUs 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 acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
Healthcare Inspection - Review of Circumstances Leading to a Pause in Providing Inpatient Care, VA Northern Indiana Healthcare System, Fort Wayne, Indiana
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13-00670-265

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that VHA develop policy for guidance when major clinical services are paused at a VA facility.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 8/28/2014
We recommended that the VISN Director ensure that a review of the facility ICU level of care and support services is completed to determine the appropriate designation.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 8/28/2014
We recommended that the VISN Director ensure that qualified clinical staff are available to provide care.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 8/28/2014
We recommended that the VANIHCS Director ensure that efforts continue to recruit qualified staff for vacant leadership positions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that the VANIHCS Director ensure that nurse competencies are consistently completed and validated annually.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that the VANIHCS Director ensure that the facility fully implement the nurse staffing methodology and complete all required steps.
Healthcare Inspection - Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities
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13-01987-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2014
We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2014
We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities
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13-01189-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2014
We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Healthcare Inspection - Follow-Up Assessment of Radiation Therapy, VA Long Beach Healthcare System, Long Beach, California
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13-00696-254

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2013
We recommended that the Under Secretary for Health ensure that repeated deficiencies in the documentation of patient care are addressed and do not persist.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2013
We recommended that the VISN Director ensure that complications of radiation therapy that are managed at referring facilities are reported to the facility where radiation therapy was provided.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2014
We recommended that the VISN Director require that the facility Director ensure that radiation therapists adhere to local policy when shifts in the field of delivered radiation occur.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that the VISN Director require that the facility Director ensure that adverse events in the Radiation Oncology department are consistently reported to facility managers as specified in the facility’s action plan in response to the 2011 OIG report.
Inspection of VA Regional Office Waco, Texas
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13-00368-244

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2014
We recommend the Waco VA Regional Office Director conduct a review of the 795 temporary 100 percent disability evaluations remaining from the data we used to perform the inspection and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2014
We recommend the Waco VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of the training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommend the Waco VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration policy requiring second-signature review of each traumatic brain injury claim processed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommend that the Waco VA Regional Office Director develop and implement a plan to ensure staff follow Veterans Benefits Administration policy in including recommendations for identified problems in their Systematic Analyses of Operations.
Healthcare Inspection – Review of a Patient with Medication-Induced Acute Renal Failure, Amarillo VA Health Care System, Amarillo, Texas
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13-01988-253

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2013
We recommended that the System Director consult with Regional Counsel to determine if a disclosure of the events related to the patient's episode of acute renal failure, as discussed in this report, is indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2014
We recommended that the System Director ensure that the Chief of Staff conduct a thorough review of the care provided to this patient by the system.
Inspection of VA Regional Office Jackson, Mississippi
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13-00709-257

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record and schedule medical reexaminations as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to review the 195 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: 3/11/2014
We recommend the Jackson VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration and local second-signature requirements for traumatic brain injury claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/11/2013
We recommend the Jackson 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.
Community Based Outpatient Clinic Reviews at Hunter Holmes McGuire VA Medical Center, Richmond, VA
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13-00026-258

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the 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: 12/4/2013
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: 7/26/2013
We recommended that the PSB submits actions and recommendations for privileging and reprivileging to the MPSC and that meeting minutes reflect documents reviewed and the rationale for privileging or reprivileging at the Charlottesville and Emporia CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers minimize risks associated with the handling, storing, and disposing of hazardous materials in the hazardous waste storage room at the Charlottesville CBOC.
Combined Assessment Program Review of the Sioux Falls VA Health Care System, Sioux Falls, South Dakota
|
13-01674-256

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scale scores upon change in condition and/or at discharge and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that acute care staff revise interprofessional treatment plans when there are risk level changes and that compliance be monitored.
Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania
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13-01672-260

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
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)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that a process be established to track HPC consults that are not acted upon within 4 days of the request.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that interdisciplinary care plans are completed for all HPC inpatients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that processes be strengthened to ensure that HPC inpatients pain is consistently reassessed and that results are documented timely in EHRs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that monthly DCHV Program and SA domiciliary self-inspection documentation includes all required elements.
Community Based Outpatient Clinic Review at Jack C. Montgomery VA Medical Center, Muskogee, OK
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13-00026-259

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of abnormal cervical cancer screening 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: 2/25/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of the results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Community Based Outpatient Clinic Reviews at Amarillo VA Health Care System, Amarillo, TX and Northern Arizona VA Health Care System, Prescott, AZ
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13-00026-252

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: 1/28/2014
We recommended that a process be established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening 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: 1/28/2014
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2014
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians administer tetanus vaccines when indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2014
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2014
We recommended that the PSB grants privileges consistent with the services provided at the Lubbock CBOC.
Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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13-01123-249

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: 2/28/2014
We recommended that the facility Director ensure that the patient (case 1) endof-life care undergoes a quality review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director ensure that CLC staff are appropriately trained and competent to care for all CLC residents, regardless of the residents' special care needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that the facility Director conduct a risk assessment of the electronic monitoring system and implement improvements, as indicated.
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