All Reports

Alleged Deficiencies in Oncology Psychosocial Distress Screening and Root Cause Analysis Processes at a Facility in VISN 15
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19-06562-30

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2020
The Veterans Integrated Service Network Medical 15 Facility Director conducts an evaluation of radiation oncology clinic mental health consultation and treatment program needs and adjusts mental health provider coverage as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The Veterans Integrated Service Network Medical 15 Facility Director ensures that all components of the oncology service psychosocial distress screening standard operating procedures include screening frequency consistent with National Comprehensive Cancer Network’s ideal standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2020
The Veterans Integrated Service Network Medical 15 Facility Director guarantees that the patient safety program maintains effective processes to track action items to completion and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2020
The Veterans Integrated Service Network Medical 15 Facility Director ensures that staff complete Suicide Behavior and Overdose Reports and Behavioral Health Autopsies, as required by the Veterans Health Administration.
Comprehensive Healthcare Inspection of the VA Butler Health Care Center, Pennsylvania
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19-00049-43

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff ensures that the Medical Executive Committee considers and documents the deliberation of professional practice data prior to granting privileges and monitors committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
Delays and Deficiencies in Management of Selected Radiology and Nuclear Medicine Outpatient Exams
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18-02300-236

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
Ensure facility staff evaluate scheduling workload and that medical support assistant staffing is adequately distributed for scheduling radiology exam requests in a timely manner.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Provide formal guidance to facilities for establishing clinic management models for adequate radiology resources, including staffing and equipment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2021
Ensure facility radiology and nuclear medicine services monitor exam requests pending greater than seven days and address them in a timely manner.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
Confirm with each facility director that they reviewed each record and took appropriate action as they deemed necessary for the three completed requests with additional follow-up care needs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Develop and implement a plan for improved radiology and nuclear medicine oversight at the Veterans Integrated Service Network level.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2021
Implement a mechanism to routinely audit canceled exam requests, ensuring the requests are in accordance with VA radiology and nuclear medicine policies and procedures for canceling exam requests, and taking corrective actions as needed based on audit results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Create a method to notify radiology and nuclear medicine leaders at all VA medical facilities when guidance is released. The method should be streamlined with maximum distribution and ensure receipt and acknowledgment by affected radiology and nuclear medicine leaders.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
Confirm with each facility director that they review each record and take appropriate action for five of the six canceled requests with outstanding exam needs.
Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System, Honolulu, Hawaii
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19-00023-29

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff confirms that clinical managers ensure that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The associate director for Patient Care Services ensures staff remove expired medications from service and monitors staff compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The associate director for Patient Care Services makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The associate director makes certain staff use privacy screens on all computer monitors located in public areas and monitors staff compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The associate director ensures that the Leeward Oahu VA Clinic waiting room carpet is replaced.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff ensures that Leeward Oahu VA Clinic staff secure laboratory transport boxes containing personally identifiable information and monitors staff compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The facility director ensures that controlled substances inspectors verify controlledsubstances orders for five random dispensing activities during monthly area inspectionsand monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff confirms that mental health and primary care providers completemilitary sexual trauma mandatory training within the required time frame and monitorsproviders’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2020
The chief of staff confirms that the Women Veterans Health Committee is comprised of required members and monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The chief of staff makes certain that program managers collect and track cervical cancer screening notification, results reporting, and follow-up care data and monitors program managers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Comprehensive Healthcare Inspection of the Northern Arizona VA Health Care System, Prescott, Arizona
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19-00014-33

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.
Comprehensive Healthcare Inspection of the Sioux Falls VA Health Care System, South Dakota
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19-00019-26

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2020
The chief of staff ensures that the imaging service chief includes the minimum required specialty-specific criteria for focused professional practice evaluations of nuclear medicine practitioners and monitors imaging service chief’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The associate director confirms that facility managers replace or remove damaged furnishings and wheelchairs from service and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substance orders and monitors inspectors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregivers education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The facility director ensures the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The facility director makes certain that the emergency department is staffed with a minimum of two registered nurses during all hours of operation and monitors compliance.
Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Boston VA Research Institute
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18-00711-211

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC),Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The under secretary for health confer with VA Office of General Counsel and the VA Boston Healthcare System Human Resources Office to determine if administrative actions should be taken concerning VA Boston Healthcare System officials responsible for the $1.6 million in inappropriate payments to the Boston VA Research Institute.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The under secretary for health determine appropriate actions for the inappropriate overpayments, made by VA Boston Healthcare System officials, associated with salaries and fringe benefits for ineligible Boston VA Research Institute administrative staff, as well as duplicate employer retirement contribution payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Human Resources Office develops procedures to require reviews of VA-affiliated nonprofit corporation Intergovernmental Personnel Act agreements for compliance with VA Handbook 5005, Staffing, prior to approval.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Research and Development Budget Office develops procedures for adequate review of VA-affiliated nonprofit corporation invoices to prevent duplicate payments in accordance with VA financial policy prior to approval.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The VA Boston Healthcare System director determine appropriate actions to ensure procedures are developed that require the VA Boston Healthcare System Research and Development Budget Office supervisor to conduct periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The VA Boston Healthcare System director establish procedures to ensure research and development budget office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with the agreement prior to payment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The VA Boston Healthcare System director establish procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff to prevent improper payments, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 45,903,000.00
Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System, California
|
18-04671-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2021
The chief of staff ensures that clinicians complete peer reviews for all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The associate director for Patient Care Services ensures utilization management reviewers complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors reviewers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The associate director for Patient Care Services ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The associate director for Patient Care Services makes certain that staff label multidose medication vials with an expiration date upon opening and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The associate director for Operations ensures that managers maintain a safe environment in patient care areas and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The associate director for Operations ensures that San Luis Obispo VA Clinic staff secure laboratory transport bags containing personally identifiable information and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2020
The associate director for Operations ensures the VA police document response times for panic alarm testing at the locked inpatient mental health unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The associate director for Operations makes certain that bathroom faucets in the inpatient mental health unit are in compliance with the Mental Health Environment of Care Checklist and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The facility director ensures that the controlled substances coordinator’s monthly summary report includes all discrepancies and findings identified during inspections and monitors coordinator’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2020
The facility director makes certain that a quality management committee consistently reviews monthly and quarterly controlled substances program trend reports, including discrepancies identified during inspections, and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The facility director makes certain that controlled substances inspectors are appointed in writing to a term not to exceed three years and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director ensures that the controlled substances coordinator performs and documents competency assessments of the controlled substances inspectors annually and monitors controlled substances coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director confirms that controlled substances inspectors complete monthly inspections and physical inventory counts and monitors inspectors’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors program staff’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2022
The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The facility director makes certain that the controlled substances coordinator refrains from conducting routine inspections and monitors coordinator’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2021
The facility director confirms that controlled substances inspectors complete monthly pharmacy inspections and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2022
The facility director ensures that controlled substances inspectors verify that drugs held for destruction are secured and documented during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2021
The facility director makes certain that controlled substances inspectors verify the inventory count of prescription pads the day of the pharmacy inspection and monitors inspectors’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2021
The facility director ensures that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The facility director guarantees that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2021
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2021
The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The chief of staff ensures that the Women Veterans Health Committee includes required core members, meets at least quarterly, and reports to facility leaders and monitors committee’s compliance.
Alleged Wrongful Death and Deficiencies in Documentation of a Patient’s DNAR Status at the Baltimore VA Medical Center, Maryland
|
19-05916-24

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2020
The VA Maryland Health Care System Director reviews the subject patient’s final episode of care and treatment course and determines if administrative actions are appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2021
The VA Maryland Health Care System Director establishes a process to monitor the identification, documentation, and communication of patients’ Do Not Attempt Resuscitation status.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Maryland Health Care System Director reviews the process for tracking, documenting, and completing action items in the Executive Committee of the Medical Staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The VA Maryland Health Care System Director strengthens the process for tracking code blue/rapid response events to include timely completion of the required documentation and accountability for delinquent documentation.
Comprehensive Healthcare Inspection of the El Paso VA Health Care System, Texas
|
19-00033-11

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures that mental health service chiefs clearly define and communicate expectations for focused professional practice evaluations in advance with providers and monitors service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures the emergency management coordinator conducts an annual inventory of resources and assets and monitors coordinator’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The facility director ensures that an emergency operations plan that describes the response procedures to follow when emergencies occur is developed and maintained as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The chief of staff makes certain that the Women Veterans Health Committee reports to leaders with signed minutes and monitors committee’s compliance.
Comprehensive Healthcare Inspection of the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
|
18-04667-13

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The chief of staff ensures clinical managers initiate focused professional practice evaluations that clearly define criteria and communicate time frames in advance and monitors clinical managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The facility director ensures that pharmacy staff who review monthly balance adjustments do not have electronic access to perform controlled substances balance adjustments and monitors staff compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The facility director confirms that the Women Veterans Health Committee maintains an active charter, meets quarterly at a minimum, and reports to leadership with signed minutes and monitors committee’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The chief of staff ensures providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.
Comprehensive Healthcare Inspection of the Manchester VA Medical Center, New Hampshire
|
19-00040-10

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: 10/19/2020
The facility director confirms that the patient safety manager includes consideration of relevant literature in root cause analyses and monitors patient safety manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The chief of staff ensures that clinical managers document in practitioners’ profiles the focused professional practice evaluation criteria defined in advance and monitors clinical managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The chief of staff ensures that professional practice evaluations include service-specific criteria and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The chief of staff confirms that specialty providers’ ongoing professional practice evaluations include the minimum required specialty criteria and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The chief of staff makes certain that the facility’s Medical Executive Council reviews the professional practice data in the consideration to continue provider privileges and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The associate director ensures that a clean and safe environment is maintained throughout the facility and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The facility director ensures that military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The chief of staff ensures providers offer referrals for military sexual trauma-related services for patients with a positive screen and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The chief of staff ensures providers document indication for use for newly prescribed medications in patients’ electronic health records and monitors providers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The chief of staff ensures providers reconcile medication information and resolve discrepancies and monitors the providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center, Augusta, Georgia
|
19-00013-15

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: 4/14/2020
The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors manager compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The chief of staff ensures that final peer reviews are completed within 120 calendar days from the determination of the need for the review, or there is an extension approved in writing by the director, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The facility director makes certain that a summary of the Peer Review Committee’s work is reviewed quarterly by the executive level medical committee and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2021
The chief of staff makes certain that service chiefs define and communicate expectations for focused professional practice evaluation criteria in advance and maintain appropriate documentation of the processes and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2020
The associate director ensures a clean and safe environment is maintained throughout the facility and monitors team’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The associate director ensures the facility maintains an inventory of assets and resources available in the event of a disaster and that it is reviewed annually and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The associate director validates that the facility’s emergency operations plan includes all required elements and is reviewed annually and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that the controlled substances coordinator submits monthly summary of findings and quarterly trends, that include discrepancies and vulnerabilities, to the director and monitors controlled substances coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The facility director makes certain that the appropriate quality management committee reviews the controlled substances monthly and quarterly reports at least on a quarterly basis and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain the controlled substances coordinator conducts required annual competency assessments of the controlled substances inspectors and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substances in storage areas on the day initiated and monitors inspectors’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that reconciliation of one day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during monthly controlled substances area inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substances orders during monthly area inspections and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that controlled substances inspectors verify, during monthly inspections, there is a corresponding sealed evidence bag containing drug(s) for each destruction holding number listed on the “Destructions File Holding Report” and monitors inspector’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director ensures that controlled substances inspectors complete verification of prescription pad inventories count during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director ensures that the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances prescriptions during monthly area inspections and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that controlled substances inspectors complete the verification of the 72-hour inventory and monitors inspectors’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The chief of staff ensures providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The facility director confirms that the committee responsible for Women Veterans Subcommittee meets quarterly and includes required core members and monitors committee’s compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director ensures that assigned staff implement a process to track and follow-up on findings from cervical cancer screenings and monitors staff’s compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The chief of staff ensures that a backup call schedule is maintained for emergency department providers and monitors the department’s compliance.
VHA Did Not Effectively Manage Appeals of Non VA Care Claims
|
18-06294-213

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate identifies its facilities that receive appeals but do not have sufficient staff assigned to process them, and then promptly transfers unprocessed appeals from those facilities to a Payment Operations and Management appeals-processing facility to ensure they are processed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate updates communications to direct claimants to submit appeals to its facilities with designated appeals-processing staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health clearly define the roles and responsibilities of an accountable OCC official to oversee the Payment Operations and Management directorate’s appeals function.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates effective policies and procedures for its staff to promptly process their pending appeals workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate completely and accurately identifies and records its pending appeals inventory in a standard system of record and implements controls to effectively maintain the pending appeals inventory in the system of record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure all Payment Operations and Management directorate appeals processors obtain access to Caseflow promptly, and that Caseflow includes fields that are necessary to effectively manage Payment Operations and Management appeals.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates to all staff effective policies and procedures for processing and managing appeals under the new appeals process, including timeliness standards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate completes a comprehensive assessment of its appeals workforce and inventory, and then reevaluates its appeals staffing needs.
Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System, West Haven, Connecticut
|
18-04675-23

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: 10/19/2021
The chief of staff ensures that service chiefs clearly define and share in advance the expectations for the focused professional practice evaluation process with providers and monitors the service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that service chiefs include service/section-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that service chiefs’ determination to continue current privileges is based, in part, on results of ongoing professional practice evaluation activities and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The facility director ensures that the Medical Staff Executive Council documents consideration of focused and ongoing professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Staff Executive Council’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that an adequate number of controlled substances inspectors are appointed in writing prior to performing inspector duties to a term not to exceed three years and monitors the compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures that a controlled substances inspector does not inspect the same controlled substances area for two consecutive months and monitors inspectors’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures that monthly reconciliation of one-day’s dispensing from pharmacy to every automated dispensing cabinet and one-day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures that the controlled substances coordinator refrains from conducting routine inspections of controlled substance storage areas and monitors inspector’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that the nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The chief of staff ensures providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
Deficiencies in Sterile Processing Services and Decreased Surgical Volume at the VA Connecticut Healthcare System, Newington and West Haven, Connecticut
|
19-00075-14

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The Veterans Integrated Service Network 1 Director provides oversight for the timely implementation of Office of Inspector General recommendations directed to the VA Connecticut Healthcare System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The Veterans Integrated Service Network 1 Director ensures the timely completion of hiring actions at the VA Connecticut Healthcare System until staffing deficiencies in Sterile Processing Services and Facility Management Services are fully resolved.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures clinical leaders with working knowledge of and/or expertise in operating room, surgery, and Sterile Processing Services are included in the decision-making and resolution of Sterile Processing Service remediation efforts.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The VA Connecticut Healthcare System Director ensures the development and implementation of a clear action plan to establish communication, foster collaboration, and restore system staff trust in system leaders, and, as necessary, consult with Veterans Health Administration’s National Center for Organizational Development.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The VA Connecticut Healthcare System Director provides oversight for the timely completion of the projects impacting Sterile Processing Services and Surgical Services that remain pending.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The VA Connecticut Healthcare System Director ensures that the development, review, and revision of standard operating procedures is completed, and that a sustainable process is in place to maintain standard operating procedures.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures that all Sterile Processing Services staff complete and maintain Sterile Processing Services training and competencies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures that Sterile Processing Services leaders maintain a staffing plan that includes an accurate number of authorized positions that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures that surgery and anesthesia staff evaluate the readiness of all supplies and equipment for use before anesthetizing a patient.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The VA Connecticut Healthcare System Director evaluates and reports the impact on and identified needs of the VA Connecticut Healthcare System residency program.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The VA Connecticut Healthcare System Director works collaboratively with Veterans Integrated Service Network 1 Director to ensure the timely implementation of future Sterile Processing Services planned projects.
Two Patient Suicides, a Patient Self-Harm Event, and Mental Health Services Administrative Deficiencies at the Alaska VA Healthcare System, Anchorage, Alaska
|
19-00002-16

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director ensures that staff are educated and trained on missing patient policies and procedures, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director makes certain that managers establish a unified Same Day Access Clinic policy, educates staff on the policy, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2020
The Alaska VA Healthcare System Director ensures a psychiatric coverage plan for the Same Day Access Clinic for all hours of operation that includes a contingency plan for psychiatric providers’ unavailability.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director establishes clearly defined Same Day Access Clinic hours that are consistent with the Same Day Access Clinic policy and signage.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2020
The Northwest Network Director strengthens the Alaska VA Healthcare System leaders’ adherence to the scheduling directive reporting structure as required by the Veterans Health Administration.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director implements standardized clinically indicated date and return to clinic order procedures, and staff training, and monitors for compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director establishes a missed appointment policy, ensures that staff are educated on the policy, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2020
The Alaska VA Healthcare System Director facilitates the full implementation of a Behavioral Health Interdisciplinary Program, as required by the Veterans Health Administration.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director ensures staff training on the Mental Health Treatment Coordinator policy established on February 1, 2019, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The Alaska VA Healthcare System Director establishes a behavioral health emergency policy, ensures that staff are educated on the policy, and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2020
The Northwest Network Director ensures that the Alaska VA Healthcare System Director evaluates the culture, morale, and leadership issues identified by the alternative dispute resolution specialist in this report and takes appropriate action as necessary.
Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital, Tampa, Florida
|
19-00011-255

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: 4/22/2020
The chief of staff ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2020
The chief of staff ensures that service chiefs clearly define and share in advance the expectations, outcomes, and time limits for focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2019
The facility director makes certain that the pharmacy or nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff compliance
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2020
The facility director confirms providers complete military sexual trauma mandatory training no later than 90 days after assuming their position and monitors providers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2020
The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and assess understanding of the education provided and monitors clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2020
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
Records Management Center Disclosed Third-Party Personally Identifiable Information to Privacy Act Requesters
|
19-05960-244

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits implements the Veterans Benefits Administration’s commitment to update its Privacy Act release policy and begin redacting third-party personally identifiable information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits ensures VA’s website is updated to reflect current Veterans Benefits Administration policy regarding release of third-party personally identifiable information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2021
The Under Secretary for Benefits implements a plan to ensure the Records Management Center complies with requirements for mailing Privacy Act responses in accordance with VA Directive 6609.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits establishes a plan to ensure that Records Management Center management receives a report for any site visit of the Records Management Center completed by the Veterans Benefits Administration and takes corrective action as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Records Management Center director implements a plan to improve quality reviews and ensures staff are held accountable for the accuracy of their Privacy Act releases.
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