All Reports

Healthcare Inspection – Quality of Care Issues, Erie VA Medical Center, Erie, PA, and VA Pittsburgh Healthcare System, Pittsburgh, PA
|
13-01855-336

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2014
We recommended that the Veterans Integrated Service Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2014
We recommended that the Veterans Integrated Service Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible disclosure to the surviving family member(s) of the patient.
Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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13-02316-322

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
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: 5/19/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, and daily monitoring for a change in condition 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: 6/17/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
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 being discharged and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that the facility establish staff pressure ulcer education requirements and 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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2014
We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that all designated employees complete respirator fit testing and that compliance be monitored.
Community Based Outpatient Clinic Reviews at Sheridan VA Healthcare System, Sheridan, WY
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13-00026-316

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2014
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: 2/11/2014
We recommended that MSDS are kept current at the Casper and Riverton CBOCs and that staff is trained in accessing MSDS for hazardous chemicals in the clinical area at the Casper CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that managers ensure all exit routes are clearly identified at the Riverton CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2014
We recommended that testing of the panic alarm system is documented at the Casper and Riverton CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that the Chief of OI&T implements required measures at the Casper CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2014
We recommended that EOC deficiencies are tracked, trended, and corrected at the Casper and Riverton CBOCs.
Healthcare Inspection – Inadequate Staffing and Poor Patient Flow in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland
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12-03887-319

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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 the Facility Director develop action plans that address emergency department patient flow and length of stay, including specialty bed access.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director develop an emergency department staffing policy that includes a contingency plan for additional physician and nurse staffing when patient care demands exceed available staffing resources.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director ensure that data collection and the reporting process are strengthened.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommend that the Facility director ensure that a local diversion policy is developed and implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director ensure that the patient flow committee meets regularly, membership is reviewed for appropriateness, and follow-up actions are monitored.
Review of Alleged System Duplication in VA’s Virtual Office of Acquisition Software Development Project
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12-02708-301

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/18/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/8/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,000,000.00
Community Based Outpatient Clinic Reviews at James A. Haley Veterans' Hospital, Tampa, FL
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13-00026-314

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
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: 1/24/2014
We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that fire drills be completed at the Zephyrhills CBOC as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that signage is installed at the New Port Richey and Zephyrhills CBOCs that clearly identifies fire extinguisher locations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that patient privacy is maintained as required at the New Port Richey and Zephyrhills CBOCs.
Healthcare Inspection – An Unexpected Death in a Mental Health Treatment Program, VA New Jersey Health Care System, Lyons, New Jersey
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13-01498-318

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2014
We recommended that that the Health Care System Director ensures that the Mental Health Residential Rehabilitation Treatment Program complies with local and VHA Mental Health Residential Rehabilitation Treatment Program Safe Medication Management policy requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2014
We recommended that the Health Care System Director ensure that Mental Health Residential Rehabilitation Treatment Program documentation is individualized, timely, and includes required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2014
We recommended that the Health Care System Director ensure that Mental Health leadership provides appropriate professional support for Mental Health Residential Rehabilitation Treatment Program mid-level providers.
Audit of VBA's Veterans' Retraining Assistance Program Participation
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12-04524-321

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they must monitor VA students' attendance and grades for satisfactory academic progress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they are required to report VA students' changes in enrollment to VBA within 30 days.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits revise the certifying official handbook to state a veteran's signed statement should not be used as the only means of verifying attendance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they need to accurately report credit hours and class terms in the VA ONline Certification of Enrollment system.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2014
We recommend the Under Secretary for Benefits include language on the Interactive Voice Response scripts to warn veterans of the potential penalty for certifying false enrollment information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2014
We recommend the Under Secretary for Benefits implement a plan to monitor veterans currently enrolled at the schools that had their approval withdrawn or suspended to ensure they meet Veterans Retraining Assistance Program full-time attendance requirements and are making positive progress towards program completion.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 12,000,000.00
Healthcare Inspection – Laboratory Delays and Alleged Staff Training Issues, Memphis VA Medical Center, Memphis, Tennessee
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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
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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
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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

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 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

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 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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
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

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 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
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