All Reports

Facility Leaders’ Oversight and Quality Management Processes at the Gulf Coast VA Health Care System in Biloxi, Mississippi
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17-03399-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Veterans Integrated Service Network 16 Director oversees implementation of recommendations directed to the Gulf Coast VA Health Care System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that providers with previous licensure issues or malpractice cases meeting the Veterans Health Administration indicated threshold for Veterans Integrated Service Network Chief Medical Officer review, are approved by the Veterans Integrated Service Network Chief Medical Officer prior to appointment of the provider to the medical staff 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: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that Focused and Ongoing Professional Practice Evaluations are completed in accordance with Veterans Health Administration policy and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The Gulf Coast VA Health Care System Director ensures that actions are taken to ensure processes are followed to review and report providers, when indicated, to the National Practitioner Data Bank and state licensing boards in the timeframe required by Veterans Health Administration policy and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director reviews the circumstances surrounding the failure to report the surgeon to all licensing boards in states where the surgeon held active licenses in December 2017 and takes action, if necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that the Executive Committee of the Medical Staff’s meeting minutes provide sufficient detail to allow tracking of medical management decisions and problem solving and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2020
The Gulf Coast VA Health Care System Director determines the scope of previously administratively closed incomplete notes in patient electronic health records that have been administratively closed to ensure compliance with Veterans Health Administration policy and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2020
The Gulf Coast VA Health Care System Director tracks and monitors the process used to administratively close incomplete electronic health record notes by providers who no longer work at the Gulf Coast VA Health Care System.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures and monitors that protected information contained in the Facility Surgical Workgroup minutes is maintained on a secure intranet site in alignment with Veterans Health Administration policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director confirms that patients’ care whose death occurred within 30 days of a surgical procedure are reviewed and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2020
The Gulf Coast VA Health Care System Director ensures that required staff maintain basic life support and advanced cardiac life support certification as required by Veterans Health Administration policy and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Gulf Coast VA Health Care System Director makes sure that required Gulf Coast Health Care System services submit monthly basic life support and advanced cardiac life support compliance reports to the Critical Care Committee.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director verifies that monthly basic life support and advanced cardiac life support compliance reports are provided to the Executive Committee of the Medical Staff as required by Gulf Coast VA Health Care System policy and monitors for compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes sure that Patient Safety Committee meeting minutes reflect a discussion of patient safety activities as required by Gulf Coast VA Health Care System policy and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes certain that past and future adverse events are reported to the patient safety manager as defined in Gulf Coast Health Care System policy and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that at least one proactive risk assessment is completed every 18 months for The Joint Commission accredited programs as required by Veterans Health Administration policy and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes certain that an effective process is in place to identify and review cases where an institutional disclosure may be indicated and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Gulf Coast VA Health Care System Director reviews the eight identified events that met criteria for consideration of an institutional disclosure as required by Veterans Health Administration policy and takes action as warranted.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that Administrative Investigation Boards are completed within the 45-calendar day timeframe required by Veterans Health Administration policy and monitors compliance.
Pathology Processing Delays at the Memphis VA Medical Center, Tennessee
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18-02988-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Veterans Integrated Service Network Director ensures that Memphis VA Medical Center leaders assess staffing needs, to include factors impacting the ability to recruit and retain staff, develop plans to improve staffing and assist in hiring to staff Pathology and Laboratory Medicine Service as required by the Clinical Laboratory Improvement Amendment and Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director verifies the development and implementation of a formal process to track surgical pathology specimens sent out of the Memphis VA Medical Center for processing and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures a comprehensive assessment of the Pathology and Laboratory Medicine Service to identify specific root causes of surgical pathology specimen delays and ensure steps are taken to prevent risk of future occurrences.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures that Pathology and Laboratory Medicine Service leaders provide an ongoing, comprehensive Quality Management program that identifies the availability of accurate, reliable, and timely test results, and reports to the ordering providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2020
The Memphis VA Medical Center Director ensures compliance with required surgical pathology Quality Assurance policies and practices, and that Memphis VA Medical Center leaders monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures that an ongoing process is developed and implemented for Memphis VA Medical Center oversight of Pathology and Laboratory Medicine Service quality data, that includes documentation of the discussion of quality assurance and analysis of the data and the development of action plans as needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director verifies that all Pathology and Laboratory Medicine Service employees that perform patient testing have updated competencies and documented training on their assigned duties.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2020
The Memphis VA Medical Center Director ensures that Memphis VA Medical Center leaders understand the importance of the issue brief process and comply with the Deputy Under Secretary for Health and Operations Guidance.
Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida
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19-07429-195

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The West Palm Beach VA Medical Center Director ensures that mental health multidisciplinary treatment plans are completed in accordance with Veterans Health Administration and The Joint Commission guidelines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding the Interdisciplinary Safety Inspection Team and its associated functions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding Mental Health Environment of Care Checklist training prior to entry on unit 3C and annually thereafter.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The West Palm Beach VA Medical Center Director ensures that the Employee Education Service staff assigns Mental Health Environment of Care Checklist on-line training modules to employees according to their duties and assignments.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The West Palm Beach VA Medical Center Director ensures that deficiencies identified during the Mental Health Environment of Care Checklist inspections are abated according to VHA guidelines, and that appropriate risk mitigation strategies are implemented as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Veterans Integrated Service Network Director ensures that the appropriate Veterans Integrated Service Network level staff complies with guidelines to review semi-annual reports and follow-up to ensure abatement of deficiencies prior to item closure on the Mental Health Environment of Care Checklist.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Under Secretary for Health takes action to ensure that the Mental Health Environment of Care Checklist Work Group reviews and ranks hazards as submitted through the Patient Safety Assessment Tool, and ensures abatement (or waiver of abatement), as indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that patient safety and law enforcement cameras are installed, tested, and monitored according to West Palm Beach VA Medical Center and Veterans Health Administration guidelines.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that a policy on 15-minute safety rounding expectations be developed, and that all permanent and temporarily-assigned staff performing 15-minute safety rounding on unit 3C receive appropriate training regarding their duties.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director develops a mechanism to confirm staff compliance with 15-minute rounding requirements.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that managers and leaders with mental health, environment of care, and patient safety-related responsibilities are knowledgeable about areas and policies governing the areas under their purview.
Comprehensive Healthcare Inspection of the Central California VA Health Care System Fresno, California
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19-00006-191

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
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: 4/7/2020
The chief of staff ensures that service chiefs initiate and complete focused professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff ensures service chiefs include review of 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: 1/9/2020
The chief of staff makes certain that the Medical Executive Council meeting minutes consistently reflect the review of focused and ongoing professional practice evaluation results in the decision to recommend continuation of initially granted or ongoing privileges and monitors committee’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The associate director ensures that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The associate director makes certain that VA police document response time for panic alarm testing at the locked mental health inpatient unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that electronic access for performing or monitoring controlled substances balance adjustments is limited to appropriate staff and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff ensures that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
Health Information Management Medical Documentation Backlog
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18-01214-157

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Establish a policy that formally defines “medical document backlog”—specifically, the age of unscanned and unindexed medical documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2020
Implement formal controls to monitor medical document backlogs—specifically, the description of unscanned and unindexed documents, size of the backlog, and age of health records—as well as subsequent actions to reduce the backlogs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
Direct Veterans Integrated Service Networks and facilities with a backlog to allocate additional resources to help clear them.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Implement policy to require chiefs of Health Information Management to notify facility directors when a medical document backlog exists and to take appropriate action.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
Assess the scanning process, including staffing and productivity levels, within each facility to ensure authorized staffing levels can support future workload.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
Ensure facility directors act on staffing level assessments and obtain the necessary resources within scanning departments.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Implement standardized quality assurance monitoring procedures to improve accurate updating of patients’ electronic health records and completion of corrective actions when errors are identified.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Ensure original documents are retained until the scanning supervisor or designee verifies that scanning staff have met quality assurance monitoring standards established in Recommendation 7.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Develop procedures to ensure facility directors provide adequate document scanning/indexing training, consistent with Veterans Health Administration Handbook 1907.07, prior to allowing employees to scan/index documents without direct supervision and as needed for corrective actions.
VA’s Implementation of the Veterans Information Systems and Technology Architecture Scheduling Enhancement Project Near Completion
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16-03597-171

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/9/2020
The assistant secretary for information and technology and chief information officer should enforce current required project management processes with improved oversight to ensure project planning requirements are adequately defined and supported before starting information technology projects.
Alleged Delay in Surgical Care, Lack of Resident Oversight, and Improper Physician Pay at Edward Hines, Jr. VA Hospital, Hines, Illinois
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19-00004-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2020
The Edward Hines, Jr. VA Hospital Director evaluates the current surgery scheduling practices to determine if changes are required to improve communication processes, and takes action as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2020
The Edward Hines, Jr. VA Hospital Director ensures that documentation is in place that determines part-time physicians’ tours of duty and responsibilities for time and attendance and monitors compliance.
Alleged Deficiencies in Mental Health Care Prior to a Death by Suicide at the VA San Diego Healthcare System, California
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19-00501-175

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2020
The Under Secretary for Health expedites the development of a National Suicide Prevention Program policy and procedure to delineate the deactivation process of High Risk for Suicide Patient Record Flags and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2020
The San Diego Healthcare System Director ensures that processes be strengthened to ensure accurate patient medication information is reflected in medication reconciliation documentation and monitors compliance.
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
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.
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.
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
|
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
|
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
|
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
|
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.
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