All Reports

Mismanagement of a Resuscitation and Other Concerns at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi
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18-00808-186

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2020
The Gulf Coast VA Health Care System Director ensures behavior health staff at the Gulf Coast VA Health Care System follow the Emergency/Code Blue procedures for patients needing resuscitative care and compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2020
The Gulf Coast VA Health Care System Director ensures behavior health nurses adhere to Veterans Health Administration Directive 2011-016 for pronouncement of deaths.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The Gulf Coast VA Health Care System Director makes certain behavioral health unit nurses maintain basic life support competency and training (certification) and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
The Gulf Coast VA Health Care System Director evaluates the Inpatient Behavioral Health Unit 25-B nurses’ patient health record documentation (including but not limited to the observations every 15-minutes) for accurate and complete statements and takes action as necessary based on the findings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
The Gulf Coast VA Health Care System Director ensures Gulf Coast VA Health Care System policy and providers comply with Veterans Health Administration policy on the documentation requirements of provider to provider communication of transfer of behavioral health patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The Gulf Coast VA Health Care System Director reviews the policy and procedure for use of the emergency carts to include checks, expired equipment, and locked drawers and ensures compliance and oversight.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The Veterans Integrated Service Network Director evaluates the recommendations from the fact-finding review and takes action as necessary.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The Gulf Coast VA Health Care System Director complies with Veterans Health Administration policies regarding institutional disclosure.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The Gulf Coast VA Health Care System Director ensures that required documentation is completed on all basic life support events and reviewed by the critical care committee.
Non VA Emergency Care Claims Inappropriately Denied and Rejected
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18-00469-150

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Under Secretary for Health reevaluates all claims denied after April 8, 2016, for the reason of “other health insurance” for appropriate corrective action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The Under Secretary for Health implements a clearly defined decision matrix that allows staff to accurately determine when claims should be denied, rejected, or approved; initiate a process to systematically audit denied and rejected claims; and take corrective actions as needed based on audit results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The Under Secretary for Health develops and implements a control to ensure claims processors have the appropriate options in the claims-processing system of record to request evidence necessary to substantiate third-party liability claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The Under Secretary for Health reevaluates all sample claims identified in this audit as inappropriately denied and rejected for appropriate corrective action.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The Under Secretary for Health reevaluates production targets, work production credits, and application of non processing time for voucher examiners to ensure the production targets include claims research.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The Under Secretary for Health requests and ensures the Office of Resolution Management conducts an organizational assessment of the Claims Adjudication and Reimbursement processing locations where staff reported they were directed or encouraged to improperly process claims, and to take appropriate action.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The Under Secretary for Health implements strategic plans to ensure the Office of Community Care, Claims Adjudication and Reimbursement Directorate, emphasizes the accuracy of claims-processing decisions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The Under Secretary for Health implements controls to ensure eligibility for overtime, telework, and annual performance bonuses for Claims Adjudication and Reimbursement staff includes all facets of performance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2020
The Under Secretary for Health develops and implements a clearly defined and effective quality assurance program that encompasses all claims decisions and includes a standardized process for supervisors to determine and effectively monitor the extent to which claims processors accurately rejected and denied non VA emergency care claims.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities routinely communicate backlogs of incoming mail to Office of Community Care leaders with associated action plans to accurately record the date the documents were received.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2020
The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities and VA medical centers timely communicate claims decisions to veterans and providers to ensure veterans are notified of what VA needs to adjudicate the claims and what actions the veteran may take in response.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 533,000,000.00
Follow-Up Review of the Veterans Crisis Line, Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas
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18-03390-178

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The Veterans Crisis Line director ensures analysis of rescue efforts ending because the caller’s location cannot be found, identifies and analyzes metrics that may have contributed to the inability to locate these rescues, and takes remedial action.
Episodes of Non-Adherence to Privacy and Security Policies at the Tibor Rubin VA Medical Center, Long Beach, California
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17-03557-177

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2020
The Tibor Rubin VA Medical Center Director reviews the communication processes between employees and Biomedical Engineering and Information Technology departments regarding disclosure of patient sensitive information when interface issues exist and takes necessary actions to improve this communication.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
The Tibor Rubin VA Medical Center Director ensures that facility healthcare staff can identify which patient information or combination of patient information is considered protected from disclosure and staff transfers protected information across all communication modes, including emails and text pages, according to VA/Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2020
The Tibor Rubin VA Medical Center Director ensures that the Privacy Officer and the Information Systems Security Officer take necessary steps when protected patient information is compromised or possibly breached.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2020
The Tibor Rubin VA Medical Center Director considers offering credit monitoring to the 133 identified patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 8/10/2020
The VA Assistant Secretary for Information and Technology reviews and adjusts the Veterans Administration Handbook 6500.2, Management of Breaches Involving Sensitive Personal Information, to include a process and guidance to address sensitive personal information incidents and events such as the use of personal email systems to transfer and store patient sensitive information and texting with personal cell phones.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2020
The Tibor Rubin VA Medical Center Director reviews the facility’s policy and use of physical logbooks and ensures compliance with Veterans Health Administration policy.
Factors Contributing to the Death of a Ventilator-Dependent Patient at the VA San Diego Healthcare System, California
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19-06386-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2020
The VA San Diego Healthcare System Director ensures that a policy is developed, staff is trained, and compliance is monitored related to the use of the Passy-Muir® Valve on the Spinal Cord Injury unit to include: a) Staff education on ventilator alarm settings when an in-line Passy-Muir® Valve is used, b) Documentation and monitoring of ventilator settings before, during, and after Passy-Muir® Valve use, c) Documentation of length of time the Passy-Muir® Valve is in place, d) Back-up plan for monitoring patients on a Passy-Muir® Valve, e) Patient supervision while using the Passy-Muir® Valve, and f) Patient and family education on the safe use of the Passy-Muir® Valve.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2020
The VA San Diego Healthcare System Director ensures that a policy is developed for the use of ventilator anti-disconnect devices, that staff are trained, and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2020
The VA San Diego Healthcare System Director confers with the National Center for Patient Safety to determine if a National Patient Safety Advisory should be issued regarding a potential deficit in training for staff who care for ventilated patients in non-intensive care unit settings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2020
The VA San Diego Healthcare System Director ensures that Spinal Cord Injury and respiratory therapy staff are provided refresher training regarding issues to report to the Patient Safety program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2020
The VA San Diego Healthcare System Director ensures that Spinal Cord Injury leadership reviews clinical alarms annually and ensures that the review is discussed and documented in Spinal Cord Injury Leadership Committee minutes.
Concerns Related to an Inpatient’s Response to Oxycodone and Facility Actions at the Baltimore VA Medical Center, Maryland
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18-05731-176

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2019
The VA Maryland Health Care System director takes steps to ensure resident supervision meets requirements, and monitors for compliance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2019
The VA Maryland Health Care System director verifies the capture and reporting of adverse drug events to the national Veterans Health Administration Adverse Drug Event Reporting System, and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The VA Maryland Health Care System director ensures staff complete root cause analyses or aggregated reviews for adverse events as required by Veterans Health Administration policy and monitors to ensure completion.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2020
The VA Maryland Health Care System director verifies documentation of clinical disclosures when perceptible effects of an adverse event have occurred, as required, and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2020
The VA Maryland Health Care System director ensures peer reviews are evaluated according to VA Maryland Health Care System policy and monitors for compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2020
The VA Maryland Health Care System director verifies that the Surgical Work Group meets and documents minutes as required to include improvement data presentation, discussion, and performance tracking, and monitors for compliance.
Program of Comprehensive Assistance for Family Caregivers: Timely Discharges, But Oversight Needs Improvement
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18-04924-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2019
The Under Secretary for Health establishes processes to conduct matching, at least quarterly, of the records of enrolled veterans and their caregivers against the Department of Veterans Affairs’ death, incarceration, and hospitalization data to help ensure timely program discharges and to reduce the risk of improper and questionable payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2020
The Under Secretary for Health takes steps to outline in the program’s roles and responsibilities document what the veteran and caregiver responsibilities are for promptly notifying caregiver support coordinators of deaths.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2019
The Under Secretary for Health institutes a program working group to clarify inconsistencies and gaps in program guidance. Specifically, the working group should determine if incarcerated or hospitalized veterans or caregivers should adhere to different discharge requirements. The working group should also consider the time frames for discharges, a process for veterans and caregivers to reapply to or be suspended from the program following a discharge due to incarceration or hospitalization, and should initiate updating program guidance accordingly.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 938,801.00
Comprehensive Healthcare Inspection of the Amarillo VA Health Care System, Texas
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19-00007-168

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff ensures the Cardio Resuscitation Committee reviews each resuscitative episode for which the facility is responsible and monitors the committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff ensures that provider privileges contain a clearly delineated timeframe not to exceed two years and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The chief of staff makes certain that service chiefs establish and define focused professional practice evaluation criteria that include the minimum required specialty criteria, as applicable, prior to initiation of the evaluations and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff confirms that service chiefs initiate and complete focused professional practice evaluations that include clearly delineated timeframes and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff ensures that the Medical Executive Board documents consideration of focused professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Executive Board’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The chief of staff confirms that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff makes certain that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff ensures that the Medical Executive Board documents its decision to recommend continuing privileges based on ongoing professional practice evaluation results and monitors the board’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The associate director ensures staff store expired medications separately from medications available for administration and label medication vials with an expiration date upon opening and monitors staff’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The associate director ensures that staff store clean and dirty medical equipment and supplies separately and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The associate director ensures that managers test all emergency power outlets and monitors managers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The chief of staff ensures the military sexual trauma coordinator tracks military sexual trauma-related staff training and monitors the coordinator’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The chief of staff ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leaders and monitors the coordinator’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The chief of staff ensures providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
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 monitors the clinicians’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The chief of staff makes certain that program managers implement a process to track results reporting and follow-up care data for cervical cancer screenings and monitors program managers’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required timeframe and monitors providers’ compliance.
Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center, Wyoming
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18-04680-162

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief business office revenue utilization review and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The facility director ensures the patient safety manager includes all required review elements in root cause analyses and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The facility director confirms that the Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The chief of staff ensures service chiefs collect, review, and use ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The chief of staff makes certain service chiefs include the minimum required specialty-specific criteria for ongoing professional practice evaluations of gastroenterology practitioners and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The associate director ensures managers make personal protective equipment readily accessible to employees at the Rawlins VA Clinic and monitors managers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2019
The associate director makes certain that the hazard vulnerability analysis is reviewed annually and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2019
The associate director confirms that the emergency operations plan is activated twice a year and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2019
The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The associate director for Patient Care Services makes certain that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
Concerns with Access and Delays in Outpatient Mental Health Care at the New Mexico VA Health Care System, Albuquerque, New Mexico
|
17-05572-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2019
The New Mexico VA Health Care System Director ensures that outpatient mental health scheduling staff receive training to use the electronic wait list as required by Veterans Health Administration and that New Mexico VA Health Care System managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2019
The New Mexico VA Health Care System Director reviews clinic cancellation rates and develops action plans to address identified issues.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The New Mexico VA Health Care System Director reviews open and completed consult data as well as new patient data and develops action plans to address identified issues.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
The New Mexico VA Health Care System Director evaluates the underutilization of non-VA and telemental health services for the outpatient mental health department and develops an action plan to address identified issues.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The New Mexico VA Health Care System Director ensures that patients with outpatient mental health consults and return-to-clinic orders, including telemental health, are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult/return-to-clinic timeframe and that the scheduling process is monitored for compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2019
The New Mexico VA Health Care System Director and managers review provider and scheduling staffing levels and develop an action plan to address recommendations, if any, from the staffing level reviews.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2019
The New Mexico VA Health Care System Director assesses hiring practices for providers and scheduling staff and ensures positions are filled timely.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2020
The New Mexico VA Health Care System Director updates the New Mexico VA Health Care System policies, Consult Management, and Failure to Report for Scheduled Clinic Appointments, to meet Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
The New Mexico VA Health Care System Director ensures outpatient mental health staff follow Veterans Health Administration requirements for no-show patients and monitors compliance with this process.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The New Mexico VA Health Care System Director confirms that the Administrative Investigative Board recommendations and action plans are completed as required by VHA and managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2020
The New Mexico VA Health Care System Director ensures the Administrative Investigative Board process includes identification of relevant documents, records, and other information pertinent to the issues of an investigation.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
The New Mexico VA Health Care System Director evaluates the practice of marking outpatient mental health consults as complete without an appointment and without documenting a mental health risk evaluation and takes action as necessary.
Alleged Inadequate Response to a Missing Patient and Safety Concerns at the Bay Pines VA Healthcare System, Florida
|
18-04132-163

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2020
The Bay Pines VA Healthcare System Director develops a policy to address patients with look-alike or soundalike names, educates staff on the use of the policy, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2020
The Bay Pines VA Healthcare System Director implements missing patient documentation training for staff, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2020
The Bay Pines VA Healthcare System Director ensures that staff responsible for contacting outside facilities for missing patients receive training on their duties and responsibilities, and monitors compliance.
Alleged Interference and Failure to Comply with the Pain Management Directive and the Opioid Safety Initiative at the VA Northern Indiana Health Care System, Fort Wayne, Indiana
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17-05835-165

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2020
The Veteran Integrated Service Network 10 Director ensures a case consult is made to Veterans Health Administration’s National Center for Ethics to consider whether the Chief of Staff used the position of authority in a manner intended to induce a patient management action which would have otherwise not been taken and, if so, whether the Chief of Staff’s conduct comports with a proper ethical standard.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2020
The Northern Indiana Health Care Director verifies that the Pain Management Committee is providing oversight and monitoring of pain management activities as required by Veterans Health Administration policy and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Northern Indiana Health Care Director ensures monitoring of the quality of pain assessments and the effectiveness of pain management interventions and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director develops and implements a process to evaluate the success of meeting the goals of the Veterans Health Administration National Pain Management Strategy on a regular basis, at least yearly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Northern Indiana Health Care Director establishes a formal transfer process for tertiary, interdisciplinary pain rehabilitation program referrals as required by Veterans Health Administration’s stepped care model for pain management.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director evaluates the educational programs offered to providers related to pain management and opioid safety to determine if the programs meet the intent of the Veterans Health Administration Pain Management Strategy for standardizing training and competencies and ensure that providers attend regularly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2019
The Northern Indiana Health Care Director ensures that the pain management team is operational as required by Veterans Health Administration.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2020
The Northern Indiana Health Care Director ensures that the system policy is followed for providers to routinely review an opioid risk assessment for patients on long-term opioid therapy and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director verifies compliance with the system’s pain management policy regarding patients’ requests to change providers and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2020
The Northern Indiana Health Care Director makes certain that primary care providers are utilizing the prescription drug monitoring program as required by Veterans Health Administration when prescribing opioid medication and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director ensures that primary care providers receive education on safe and effective Veterans Integrated Service Network tapering programs for patients using the combination of benzodiazepines and opioids and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director ensures that providers receive education on tapering programs for patients on high-risk opioids and monitors compliance.
Leadership, Clinical, and Administrative Concerns at the Charlie Norwood VA Medical Center, Augusta, Georgia
|
19-00497-161

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: 7/20/2020
The Veterans Integrated Service Network Director evaluates the quality and professionalism of Executive Leadership Team communications and takes action when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Veterans Integrated Service Network Director requires the development of, and follow-through on, corrective action plans responding to relevant findings from the National Center of Organizational Development’s 2018 site visits and reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director develops a process to ensure that Light Electronic Action Framework hiring requests are tracked and processed timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director reviews the facility’s hiring processes to identify opportunities to improve the efficiency and timeliness of hiring actions, and takes corrective action, as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written critical care unit bed management policy that clearly states the process to be followed when an inpatient requires intensive care and a critical care unit bed is unavailable.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written policy regarding patient-owned medical devices and equipment that clearly outlines restrictions and acceptable uses when the patient is hospitalized.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a standardized method for documenting and ensuring compliance with the internal hand-off communication policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures that neurosurgery privileges are amended to include only procedures which facility infrastructure can support.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director ensures that the nurse’s failure related to the computed tomography (CT) event outlined in this report is evaluated and administrative action is taken, as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director enhances processes to document Strategic Analytics for Improvement and Learning related improvement actions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director continues efforts to improve patient and employee satisfaction.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures prompt evaluation of sentinel events, to include root cause analyses, in accordance with Veterans Health Administration requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director evaluates the documentation failures related to Patient Y, and takes appropriate action, as indicated.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures the development of policy addressing the appropriate method for confirming and documenting nasogastric tube placement prior to administration of medications or tube feedings, including actions that should be taken when a nasogastric tube is partially dislodged.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to ensure that all registered nurses assigned to work in critical care units promptly complete assessments for missing unit-specific competencies.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to enhance processes to ensure that nursing competency skills assessments are specific to individual duty assignments and completed in accordance with Veterans Health Administration and facility policy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Charlie Norwood VA Medical Center Director ensures that critical care unit staffing decisions include contingencies for staff absences.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical care unit and emergency department nurse vacancies, and ensure that until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures that unexcused nursing absences are managed in accordance with relevant Human Resource guidelines.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2021
The Charlie Norwood VA Medical Center Director ensures that the emergency department security system is upgraded to meet current security requirements and to provide a safe environment for patients and staff.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical laboratory staff vacancies, and ensures that until optimal staffing is attained, alternate methods are consistently available that meet patient care needs.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures that before policy changes are made that impact the delivery of quality patient care, broad discussion with all key stakeholders takes place and written guidance is widely disseminated.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures that policies and procedures regarding the appropriate transfer of critically ill patients are developed in conjunction with key stakeholders and that the process is widely disseminated to relevant staff.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2021
The Charlie Norwood VA Medical Center Director ensures the Contracting Officer’s Representative responsible for the technical administration of the transportation contract conducts surveillance of the contractor’s performance and provides oversight of the contractual agreements.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The Charlie Norwood VA Medical Center Director ensures contingency plans are in place to rapidly mobilize staff when emergency department patients’ care demands exceed the current staffing resources.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures there is a signed boarder policy, which is broadly disseminated.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Veterans Integrated Service Network Director completes an assessment of the facility’s ability to assure consistent availability of services and staffing to support providers’ professional practice and the safe and timely delivery of care, and takes action as necessary.
Deficiencies in Discharge Planning for a Mental Health Inpatient Who Transitioned to the Judicial System from a Veterans Integrated Service Network 4 Medical Facility
|
18-03576-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The Veterans Integrated Service Network Director solicits an ethics consult regarding the patient’s final episode of care and treatment course including the failure to inform the patient or family of impending arrest and lack of family inclusion in decision-making.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director strengthens inpatient mental health unit processes to include the patient, family members, or surrogate in treatment and discharge planning decisions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The Facility Director evaluates the inpatient mental health unit assessment practices of patients’ decision-making capacity and voluntary admission status, and takes actions as appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director ensures that facility staff identify and document patients’ surrogates accurately.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director ensures that inpatient mental health unit discharge processes include a complete medical and psychiatric diagnostic summary to patients’ receiving mental health providers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2020
The Facility Director develops inpatient mental health unit discharge processes that include a clinical hand-off communication to patients’ receiving mental health providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director ensures that a mental health treatment coordinator is assigned for patients during all episodes and levels of mental health care.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director ensures that informed consent is obtained from patients or authorized surrogates for release of information as required.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director evaluates inpatient mental health unit admission practices and develops processes in compliance with Veterans Health Administration policy regarding voluntary and involuntary admissions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2019
The Facility Director provides guidance to clinical staff regarding access to consultative resources such as forensic mental health experts, Office of General Counsel, and Ethics Consultation Service.
Comprehensive Healthcare Inspection of the James H. Quillen VA Medical Center, Mountain Home, Tennessee
|
18-06508-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substance storage areas on the day initiated and monitors the inspectors’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director ensures that controlled substances program staff reconcile the restocking/refilling from the pharmacy to every automated dispensing cabinet for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director ensures that controlled substances program staff reconcile the return of stock from every automated dispensing cabinet to the pharmacy for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director confirms that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2020
The chief of staff makes certain that clinicians provide and document patient/caregiver education specific to the newly prescribed medication and monitors clinicians’ compliance.
Management of Major Medical Leases Needs Improvement
|
17-05859-131

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 3/10/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction ensure there are adequate funds available to routinely conduct planning activities, including developing requests for lease proposals, for Strategic Capital Investment Planning approved major leases while waiting for congressional authorization.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/15/2020
The Assistant Secretary for Management and Chief Financial Officer reconsider centralizing major medical lease acquisition funding through VA’s acceptance of the completed building.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 3/10/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction obtain adequate resources to deliver leases on schedule.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/15/2020
The Assistant Secretary for Management ensure that the prospectus cost estimates provided to Congress are accurate and the costs are allocated appropriately to comply with OMB Circular A-11 requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/15/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction implement a comprehensive VA policy for critical decisions in the lease acquisition process establishing clear lines of authority and allowable time frames.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 8/24/2021
The Deputy Under Secretary for Health for Operations and Management and the Executive Director, Office of Construction Facilities Management, ensure VA uses appropriate security measure requirements when acquiring VA major medical leases by performing Interagency Security Committee risk evaluations prior to solicitation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 3/10/2020
The Executive Director, Office of Construction Facilities Management, ensure project acquisition teams are adequately trained in performance-based acquisition.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 3/10/2020
The Executive Director, Office of Construction Facilities Management, evaluate the use of consultants in the solicitation development process for Requests for Lease Proposals of major medical leases on a case-by-case basis.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 152,300,000.00
Review of Mental Health Clinical Pharmacists in Veterans Health Administration Facilities
|
18-00037-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health ensures facility medical staff bylaws are consistent with Veterans Health Administration policy regarding clinical pharmacist practice as non-independent practitioners.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Under Secretary for Health ensures collaborating agreements, also referenced as collaborative practice agreements, are in place for mental health clinical pharmacists who provide outpatient collaborative medication management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health ensures that the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews existing Veterans Health Administration guidance and provides assistance in outlining the mental health clinical pharmacist’s responsibilities for communication with the collaborating licensed independent practitioner who has prescribing authority.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health affirms allowable clinical duties within mental health clinical pharmacists’ scopes of practice include comprehensive provisions related to mental health.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2020
The Under Secretary for Health ensures a process is in place for chiefs of mental health service to document review, recommendation, and endorsement of all outpatient mental health clinical pharmacists’ scopes of practice, regardless of whether the clinical pharmacist is aligned with the mental health service line, and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews and provides input into the patient referral process to mental health clinical pharmacists with consideration for ensuring that accurate diagnoses can be reliably identified by and conveyed to the mental health clinical pharmacists.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews the patient referral process to mental health clinical pharmacists and provides input with consideration for clinical settings or scenarios in which a review of the clinical complexity of the referral by a licensed independent practitioner with prescribing authority would be appropriate, prior to treatment.
No. 8
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director establishes guidance and provides assistance in outlining when and how mental health clinical pharmacists are to refer patients to a higher level of mental health care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The Under Secretary for Health initiates a risk assessment of outpatient mental health clinical pharmacists’ practice and establish mitigation plans; and includes the Veterans Health Administration Office of Mental Health and Suicide Prevention Director in the design, implementation, and analysis processes.
Delay in Diagnosis and Subsequent Suicide at a Veterans Integrated Service Network 15 Medical Facility
|
19-00022-153

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Under Secretary for Health ensures that the planning and implementation of the new electronic medical record includes, (a) a fail-safe system that allows communication and tracking of test results to multiple clinical staff members who coordinate patient notification, appropriate follow-up testing and clinical management, and (b) the ability to monitor actions taken by the responsible provider(s).
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director initiates an administrative review of the clinical care the patient received and takes action as appropriate based on the results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Veterans Integrated Service Network 15 Medical Facility Director ensures that Patient Centered Management Module provider and patient assignments are timely, and data are validated as required by Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2020
The Veterans Integrated Service Network 15 Medical Facility Director issues guidance that establishes a clearly-defined process for the designation of surrogates to include abnormal test results and consults.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Veterans Integrated Service Network 15 Medical Facility Director confirms that once issued, providers are trained on the process for designation of surrogates and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director reviews current view alert parameters, evaluates providers’ knowledge and management of view alerts, and takes action, as necessary, to ensure and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director evaluates communication among Patient Aligned Care Team members, including the sharing of, the timeliness of, and the response to patient secure messages, and takes action based on the evaluation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews processes within Primary Care related to patient notification of test results and takes action to ensure test results are communicated to patients as required by Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews Veterans Health Administration and the Veterans Integrated Service Network 15 Medical Facility policies concerning disclosure of adverse events to patients and/or their representatives and ensures that staff are aware of discussions and documentation required to comply with these policies.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews the events in the patient’s care and conducts additional actions related to the disclosure of adverse events to the patient’s representative as warranted by Veterans Health Administration and Veterans Integrated Service Network 15 Medical Facility.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews quality management practices and ensures compliance with Veterans Health Administration guidance related to root cause analysis when future adverse events are identified and takes action as necessary.
Staffing and Vacancy Reporting under the MISSION Act of 2018
|
19-00266-141

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 11/14/2019
Ensure VA vacancy data are reported by occupation as required by Section 505(a)(1)(c) of the Mission Act.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 11/14/2019
Make certain that VA staffing gains and losses data are reported by quarter as required by Section 505(a) part (b) of the MISSION Act.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 6/22/2020
Annotate limitations clearly within the staffing and vacancy data to improve transparency and usability of the data, to include changes from HR Smart data cleansing efforts.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 11/14/2019
Ensure that the staffing and vacancy reporting Web-site maintains historical information on the data elements required by the MISSION Act.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 6/22/2020
Update the methodology for collecting and reporting on VA staffing and vacancy data to ensure consistency in future quarters.
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