All Reports

Community Based Outpatient Clinic Reviews at VA New Jersey Health Care System, East Orange, NJ
|
13-00026-190

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that the MSEC grants privileges that are consistent with the services provided at the Paterson and Piscataway CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2014
We recommended that managers ensure that signage is installed to direct patient to handicapped parking and accessible entrance at the Paterson CBOC.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that the Chief of OI&T implements, maintains, and reviews IT closet access logs at the Piscataway CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that biohazardous waste containers at the Piscataway CBOC are stored appropriately.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that managers ensure that Paterson and Piscataway CBOC staff are trained and knowledgeable of the CBOC’s MH emergency policy.
Combined Assessment Program Review of the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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12-03746-161

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that FPPE for newly hired licensed independent practitioners are consistently initiated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2013
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2013
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2013
We recommended that the Consolidation Building have fire extinguisher signage in place in accordance with National Fire Protection Association standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2013
We recommended that processes be strengthened to ensure that post-operative patients are transported using clean elevators.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that non-HPC staff receive end-of-life training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2014
We recommended that processes be strengthened to ensure that all Home Oxygen Plan of Care notes have a physician co-signature.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that the construction and renovation activities multidisciplinary committee continues to meet.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results are documented.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that construction site inspection documentation includes all the required elements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are documented in Infection Control Committee minutes.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2014
We recommended that processes be strengthened to ensure that designated employees receive initial and ongoing construction safety training and that compliance be monitored.
Combined Assessment Program Summary Report – Evaluation of Moderate Sedation in Veterans Health Administration Facilities
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13-01743-192

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.
Community Based Outpatient Clinic Reviews at Northport VA Medical Center, Northport, NY
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13-00026-189

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2013
We recommended that access is improved for disabled veterans.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2013
We recommended that staff are trained in accessing MSDS for hazardous chemicals in the clinical area.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2013
We recommended that computer screens are secured to eliminate viewing of PII by unauthorized individuals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that laboratory specimens are secured during transport from the CBOC to the parent facility.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2013
We recommended that the server closet is maintained according to IT safety and security standards.
Community Based Outpatient Clinic Reviews at Manchester VA Medical Center, Manchester, NH
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13-00026-185

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
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.
Healthcare Inspection - Alleged Questionable Surgical Care in a VA Health Care System
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12-03743-184

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the system Director ensure that the two alleged near misses are referred to quality management staff to determine if action should have been taken.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the system Director consult with Regional Counsel regarding possible clinical disclosure to the patient for whom quality of surgical technique concerns were identified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that the system Director ensure that initial focused professional practice evaluations are completed on all newly hired providers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2013
We recommended that the system Director ensure that privileges are facility and provider specific for all providers.
Combined Assessment Program Summary Report – Evaluation of Nurse Staffing in Veterans Health Administration Facilities
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13-01744-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that all facilities fully implement the staffing methodology and complete all required steps.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that facilities improve processes to use the available data to manage and provide safe, cost-effective staffing.
Combined Assessment Program Summary Report – Evaluation of Mental Health Treatment Continuity at Veterans Health Administration Facilities
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13-01742-188

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that facilities take action to improve post-discharge follow-up for MH patients, particularly those who were identified as high risk for suicide.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that clinicians consistently follow the required processes for patients who fail to report for scheduled MH appointments and document actions taken.
Insepction of VA Regional Office Boise, Idaho
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12-03885-168

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommend the Boise VA Regional Office Director develop and implement a plan to ensure staff include recommendations for identified problems in their Systematic Analyses of Operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommend the Boise VA Regional Office Director develop and implement a plan to monitor the effectiveness of training and the local checklist to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans¿ entitlement to mental health treatment when previous decisions did not address this issue as required.
Community Based Outpatient Clinic Reviews at Robley Rex VA Medical Center, Louisville, KY
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13-00026-177

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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 a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that FPPEs are initiated for all providers who request new privileges at the Scott County CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that the facility ensure annual fire drills are completed at the Carroll County and Scott County CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that all identified EOC deficiencies at the Carroll County and Scott County CBOCs are tracked and trended until corrected.
Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2012
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12-01480-183

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2013
We recommended that the Under Secretary for Health, in conjunction with VISN senior managers, ensures that facility directors and Patient Safety Officers sit on the high-level committees that review QM results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that completed corrective actions related to protected peer review are reported to the PRC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2013
We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that FPPEs for newly hired licensed independent practitioners are initiated and completed and that results are reported to the MEC.
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
|
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
|
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
|
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
|
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
|
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
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13-00374-174

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: 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.
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