All Reports

Inspection of VA Regional Office Denver, Colorado
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12-04525-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/28/2013
We recommend the Denver VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
Community Based Outpatient Clinic Reviews at Central Arkansas Veterans Healthcare System, Little Rock, AR, and G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS
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13-00026-176

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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 managers ensure that patients with normal cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that managers ensure that cervical cancer screening results are documented in the patient's EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2014
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2014
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Russellville and Searcy CBOCs.
Healthcare Inspection - Legionnaires’ Disease at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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13-00994-180

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2014
We recommended that the VA Pittsburgh Healthcare System Director ensure that any disinfectant system in use for Legionella prevention is monitored and maintained in accordance with manufacturer’s instructions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2014
We recommended that the VA Pittsburgh Healthcare System Director ensure routine flushing of hot-water faucets and showerheads.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that the VA Pittsburgh Healthcare System Director ensure close coordination between the Infection Prevention Team and Facilities Management Service staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2014
We recommended that the VA Pittsburgh Healthcare System Director ensure that when environmental cultures are positive, actions taken comply with Veterans Health Administration guidelines.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that the VA Pittsburgh Healthcare System Director ensure that all healthcare-associated pneumonia patients are tested for Legionella infection.
Community Based Outpatient Clinic Reviews at Battle Creek VA Medical Center, Battle Creek, MI, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL
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12-03853-172

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that managers ensure that patients are notified of cervical cancer screening results within the defined timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted time frame and that notification is documented in the EHR.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that managers ensure clinicians administer pneumococcal vaccinations when indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that the Medical Executive Committee grants privileges consistent with the services provided at the Grand Rapids and Lansing CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that the Executive Committee of the Medical Staff grants privileges that are consistent with the services provided at the Evanston and McHenry CBOCs.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2014
We recommended that managers improve restroom access for disabled veterans at the Lansing CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that managers maintain a clean and functioning environment of care at the Lansing CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that managers clearly identify the location of fire extinguishers with appropriate signage at the Lansing CBOC.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2014
We recommended that managers implement a system to maintain auditory privacy during the check-in process at the Lansing CBOC.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that staff secure PII on laboratory specimens during transport from the Lansing CBOC to the parent facility.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that staff secure PII on laboratory specimens during transport from the Evanston and McHenry CBOCs to the parent facility.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that the IT server closet at the McHenry CBOC is maintained according to IT safety and security standards.
Healthcare Inspection – Patient Care Issues and Contract Mental Health Program Mismanagement, Atlanta VA Medical Center, Decatur, Georgia
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12-02955-178

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2013
We recommended that the Under Secretary for Health take note and rectify the deficiencies described in this report with respect to the provision of quality mental health care and contract management, with the goal that veterans receive the highest quality medical care from either the VA or its partners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2013
We recommended that the Facility Director evaluate the care of patients discussed in this report with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patients.
Healthcare Inspection - Mismanagement of Inpatient Mental Health Care, Atlanta VA Medical Center, Decatur, Georgia
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12-03869-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2013
We recommended that the Under Secretary for Health develops national policies that address contraband, visitation, urine drug screens, and escort services for inpatient mental health units.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2013
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit develops and implements policies that adequately address contraband, visitation, urine drug screening, and escort service.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2013
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit employs safeguards for documentation that accurately reflect staff observation of patients.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2013
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit strengthens program oversight including follow-up actions taken by leadership in response to patient incidents.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2013
We recommended that the VISN and Facility Directors ensure that the facility strengthen and improve the RCA process to ensure that all information and documentation related to the event are reviewed and that follow up actions are completed and timely.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2013
We recommended that the VISN and Facility Directors ensure that the facility improves communication with staff regarding debriefings and planned actions to address identified deficiencies.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health units are equipped with functional and well-maintained life support equipment.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommended that the VISN and Facility Directors ensure that the facility evaluates the care of the subject patient with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patient.
-Interim Report - Participation in VBA's Veterans Retraining Assistance Program
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12-04524-171

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits continue to issue certificates of eligibility until either 99,000 veterans have enrolled in an approved training program or until October 1, 2013, whichever occurs first.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits revise the Veterans Retraining Assistance Program certificate of eligibility letter to inform veterans that Veterans Benefits Administration will only pay benefits to a limited number of veterans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits contact the veterans currently holding a certificate of eligibility, who have not yet enrolled in the approved training, and inform them that VBA will pay benefits only to a limited number of veterans. Inform the veterans they will need to check the VRAP Web site or contact VBA to confirm benefits are still available before enrolling in an approved training program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2013
We recommend the Under Secretary for Benefits provide retroactive benefits to VRAP participants (not to exceed the FY 2012 authorization) who were enrolled in an approved training program in FY 2012, but did not receive benefits before October 1, 2012.
Combined Assessment Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
|
13-00431-173

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2013
We recommended that processes be strengthened to ensure that CS inspectors consistently perform and document reconciliation of 1 day's dispensing from the pharmacy to each automated unit and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2013
We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2013
We recommended that processes be strengthened to ensure that exit signs identifying alternate routes for egress are posted within construction sites.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2013
We recommended that processes be strengthened to ensure that sprinkler head paint protectors are removed as soon as possible and that in the event the protectors remain on in unattended areas for longer than 4 hours in a 24-hour period, a fire watch be implemented.
Combined Assessment Program Review of the Manchester VA Medical Center, Manchester, New Hampshire
|
13-00374-174

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
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: 12/19/2013
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the Professional Standards Board.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that the Code Committee reviews each code episode.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that managers initiate actions to address the one identified physical security deficiency and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
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 compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that the PCCT includes a dedicated psychologist and administrative support person.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the CPRS.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews HRCP activities at least quarterly.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that construction safety and infection surveillance activities related to construction projects are initiated at the same time as the projects and documented in the minutes of each committee.
Inspection of VA Regional Office Baltimore, Maryland
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12-04179-167

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/30/2014
We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure staff review all existing reminder notifications and schedule medical reexaminations as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2014
We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure that for the future, staff routinely review reminder notifications and timely schedule medical reexaminations as required.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/9/2014
We recommended the Baltimore VA Regional Office Director conduct a review of the 478 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/26/2013
We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure compliance with the Veterans Benefits Administration’s second signature requirements for traumatic brain injury claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2014
We recommended the Baltimore VA Regional Office Director develop and implement a plan to ensure staff timely address all required elements of Systematic Analyses of Operations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/26/2013
We recommended the Baltimore VA Regional Office Director develop and implement a plan outlining how Veterans Service Center staff will accomplish all required homeless veterans outreach services, including creating a resource directory and regularly contacting homeless shelters and service providers.
Healthcare Inspection - Alleged Inappropriate Surveillance James A. Haley Veterans’ Hospital Tampa, Florida
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12-03939-175

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2014
We recommended that the Under Secretary for Health ensures that VHA policy addresses the clinical uses of covert and overt video surveillance cameras in a clinical setting, including public notification, informed consent, approval, and responsibility for use of these devices, as well as detail procedures for staff to follow in obtaining video recordings for teaching, patient care and treatment, patient safety, healthcare operations, general security, and law enforcement purposes. Restrictions on the use of personal electronic devices within a VA facility to photograph and video should also be considered.
Community Based Outpatient Clinic Reviews at Dayton VA Medical Center, Dayton, OH
|
13-00026-166

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2014
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: 12/11/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that managers ensure that the facility policy for semi-annual EOC rounds includes the CBOCs and that EOC meeting minutes reflect sufficient discussion of CBOCs' issues, deficiencies, and items.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that managers ensure that staff are trained and knowledgeable of the local CBOC medical and MH emergency policy.
Inspection VA Regional Office Philadelphia, Pennsylvania
|
12-03475-169

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2013
We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration policy regarding timely benefits reduction actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2013
We recommend the Philadelphia VA Regional Office Director provide refresher training to ensure staff establish suspense diaries for temporary 100 percent.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2013
We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2013
We recommend the Philadelphia VA Regional Director develop and implement a plan to ensure staff compliance with Veterans Benefits Administration second signature requirements for processing traumatic brain injury claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/7/2013
We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly provide outreach to homeless shelters and service providers.
Combined Assessment Program Review of the Dayton VA Medical Center, Dayton, Ohio
|
13-00278-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
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 PSB.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that the scanning quality control process includes all required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect sufficient discussion of findings, action plans, and tracking of items to closure.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that managers initiate actions to address the 12 identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2014
We recommended that a process be established to track HPC consults that are not acted upon within the requested timeframe.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2014
We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed and results documented in EHRs and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that managers initiate protected peer review for the three identified patients and complete any recommended review actions.
Audit of the Community Nursing Home Program
|
11-00331-160

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2014
We recommended the Under Secretary for Health ensure Veterans Health Administration community nursing home policies are updated and reissued.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2014
We recommended the Under Secretary for Health conduct a comprehensive national review of nursing homes to ensure veterans are not placed in any nursing homes deemed ineligible by Veterans Health Administration policy, and take appropriate remedial action where necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2014
We recommended the Under Secretary for Health implement a formal oversight and communication process to ensure healthcare facilities comply with Veterans Health Administration nursing home policy and perform proper eligibility reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2014
We recommended the Under Secretary for Health establish a monitoring mechanism to ensure the Office of Geriatrics and Extended Care Strategic Healthcare Group, and healthcare facilities, use the Community Nursing Home Certification Report to monitor the nursing home program and identify high-risk nursing homes.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 296,500,000.00
Community Based Outpatient Clinic Reviews at VA Palo Alto Health Care System, Palo Alto, CA
|
13-00026-157

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that testing of the panic alarm system is documented at the Monterey CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that patients' PII are secured and protected at the Monterey CBOC.
Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California
|
13-00279-156

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are clearly defined and consistently tracked to completion at the service level.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria are reported to the Transfusion Review Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that processes be strengthened to ensure that sharps containers in the Menlo Park CLC are readily accessible to all staff.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that expired multi-dose vials are removed from medication carts in the CLC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that the facility fully implement the nurse staffing methodology.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
Administrative Investigation, Misuse of Official Time and Resources and Failure to Properly Supervise, Office of Human Resources and Administration, Washington, DC
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12-02503-151

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 Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 2/11/2014
We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take against [redacted] and ensure that action is taken.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/7/2017
We recommend that the Acting Assistant Secretary for Human Resources and Administration determine the total salary paid to [redacted] for the 39 days that [redacted] was AWOL from VA or worked for [redacted] while on sick leave and ensure that a bill of collection is issued to [redacted] for that amount, since [redacted] cannot receive pay for the period of time that [redacted] was absent without authorization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 2/11/2014
We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with OHR and OGC to determine the appropriate administrative action to take against Mr. Viani and ensure that action is taken.
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