All Reports

Review of Timeliness of the Appeals Process
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16-01750-79

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2018
The OIG recommended the acting Under Secretary for Benefits continue to monitor the effectiveness of the Veterans Benefits Administration’s appeals realignment and increased resources, towards meeting its established targets related to appeals processing timeliness.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2018
The OIG recommended the acting Under Secretary for Benefits monitor the effectiveness of the Caseflow application to ensure Board of Veterans’ Appeals decisions are timely controlled and assigned to the appropriate VA Regional Office or the Appeals Resource Center.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2018
The OIG recommended the acting Under Secretary for Benefits implement a plan to amend Veterans Benefits Administration’s procedures for closing appeals records to prevent appeals being closed prematurely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/21/2018
The OIG recommended the acting Under Secretary for Benefits remind staff of their responsibilities when processing remands and recertifying appeals to the Board of Veterans’ Appeals, and implement a plan to ensure compliance.
Comprehensive Healthcare Inspection Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee
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17-01764-143

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Chief of Staff ensures Physician Utilization Management Advisors at the Alvin C. York campus consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Facility Director ensures clinicians document patient education for patients receiving anticoagulation medication and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2020
The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2020
The Chief of Staff ensures providers consistently document patient or surrogate informed consent and the patient’s medical and behavior stability when patients are transferred out of the facility and monitors the providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2020
The Chief of Staff ensures providers countersign the acceptable designees’ transfer/progress notes when patients are transferred out of the facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Associate Director ensures that environment of care rounds are conducted at the required frequency and correctly documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Associate Director ensures ventilation grills are clean and ceiling tiles are properly maintained and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
The Chief of Staff ensures radiation safety signage is posted in each radiation area and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Associate Director ensures all mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Chief of Staff ensures that providers include review of abnormalities of major organ systems in the history and physical exams and/or pre-sedation assessments and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Chief of Staff ensures that providers inform patients when the provider performing a moderate sedation procedure is not the provider listed on the informed consent for the procedure and document the patient’s assent to the change and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2019
The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current moderate sedation training and monitors their compliance.
Review of Alleged Hazardous Construction Conditions at the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma
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15-04678-114

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure contracting officer’s representatives comply with duties assigned in the Delegation of Authority Memo.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure that on future contracts, the Chief, Engineering Service, assign contracting officer’s representatives who have experience commensurate with delegated responsibilities in accordance with the Federal Acquisition Regulation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure personnel follow established Veterans Health Administration policies on safety inspections.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, clarify the implementation of the safety inspections in Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017, to ensure the safety inspections are not performed routinely or in a discernable pattern.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure the assignment of a safety officer in accordance with Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 22,540,470.00
Comprehensive Healthcare Inspection Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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17-05402-137

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors members’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2018
The Chief of Staff ensures the Infection Prevention Committee consistently documents discussions of the high-risk elements and analysis of surveillance data and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2018
The Facility Director ensures that 1-day reconciliation of controlled substance refills to automated dispensing units in patient care areas and 1-day reconciliation of returns to pharmacy stock are performed consistently during controlled substance inspections, and the Facility Director monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2018
The Facility Director ensures that 72-hour pharmacy inventories are consistently completed during controlled substance inspections in pharmacy areas and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Chief of Staff ensures that the geriatric evaluation program receives the required oversight and that quality improvement data are regularly reviewed and documented in committee minutes, and the Chief of Staff monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Chief of Staff ensures that geriatric evaluation program registered nurses perform the required patient assessments and monitors the nurses’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Chief of Staff ensures ordering providers or designees communicate mammogram results to patients within the required timeframe and monitors providers’ compliance.
Audit of the Personnel Suitability Program
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17-00753-78

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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: 1/3/2019
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness implement the monitoring program required by policy and establish robust management oversight of the personnel suitability program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 3/28/2022
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness report the results of program monitoring activities and obtain corrective action plans from the Veterans Health Administration.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 1/3/2019
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness establish and enforce quality and performance metrics for the personnel suitability program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 7/27/2021
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness evaluate human capital needs for program oversight and facilitate the delegation or brokering of duties necessary to manage the background investigation workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 1/19/2021
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness coordinate with the Executive in Charge, Office of the Under Secretary for Health, to implement a plan to review the suitability status of all Veterans Health Administration personnel and correct delinquencies to ensure a properly vetted workforce.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, improve management oversight of the personnel suitability program at VA medical facilities and ensure background investigations are properly initiated and adjudicated nationwide, and internal control mechanisms required by policy are properly implemented.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2019
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, execute VA requirements to improve the governance of the personnel suitability program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2021
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, evaluate human capital needs and coordinate appropriate resources to manage personnel suitability workload at VA medical facilities.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 5/10/2021
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness develop and execute a project management plan to ensure sufficient and appropriate data are collected in support of suitability program objectives.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 5/10/2021
The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness ensure that personnel suitability investigation data are fully evaluated and reliable for program tracking and oversight.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 10/29/2020
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, coordinate with the Assistant Secretary for Operations, Security, and Preparedness to implement a plan to correct current data integrity issues and improve the accuracy of personnel suitability program data.
VHA Review of Selected Construction Projects at Oklahoma City VA Health Care System
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17-00253-102

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The OIG recommended the Acting Under Secretary for Health ensure the construction areas in the Surgical Intensive Care Unit project are sealed to prevent further weather damage.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2019
The OIG recommended the Acting Under Secretary for Health ensure the Oklahoma City VA Health Care System implements procedures to strengthen minor and non-recurring maintenance construction oversight.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the Acting Under Secretary for Health determine if administrative actions should be taken concerning key officials responsible for the Surgical Intensive Care Unit project.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2019
The OIG recommended the Acting Under Secretary for Health ensure the Oklahoma City VA Health Care System establishes procedures to ensure recommendations by technical experts, who perform site visits to evaluate project completion status and conformance to contract specifications as provided in design and construction contracts, are implemented.
Comprehensive Healthcare Inspection Program Review of the Providence VA Medical Center, Providence, Rhode Island
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17-01761-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data quarterly and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
The Facility Director ensures the Patient Safety Manager conducts the minimum of four individual root cause analyses each year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
The Facility Director ensures the Patient Safety Manager prepares and submits annual patient safety reports and monitors the Patient Safety Manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Chief of Staff ensures inter-facility patient transfer data are collected and analyzed as part of the facility’s quality management program and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Chief of Staff ensures that staff/attending physicians countersign transfer notes written by acceptable designees for patients transferring to another facility and monitors physicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
The Chief of Staff ensures that facility staff consistently document provision of necessary medical care within the facility’s capacity for all patients prior to transfer to another facility and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Chief of Staff ensures Radiology Service employees check the emergency cart and defibrillator according to facility policy and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Associate Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors members’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates the CNH program into the facility’s quality improvement program, and the Chief of Staff monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and monitors the team’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitors social workers’ and registered nurses’ compliance.
Comprehensive Healthcare Inspection Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
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17-01854-115

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Facility Director ensures inter-facility patient transfer data are collected and reported to the Medical Executive Committee and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and identification of transferring and receiving provider or designee in transfer documentation and monitors the clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures that transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Deputy Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Deputy Director ensures core team members consistently attend environment of care rounds and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Deputy Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures staff who perform, assist with, or supervise moderate sedation procedures have current Talent Management System moderate sedation training and monitors their compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Associate Director for Patient Care Services ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors the social workers’ and registered nurses’ compliance.
Audit of VISN 7 Power Wheelchair and Scooter Repairs
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16-04655-70

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2018
The OIG recommended the Veterans Integrated Service Network 7 Director require VA medical facility staff to input power wheelchair and scooter repair requests as soon as they are received and implement management controls to ensure repairs with closed consults are monitored to completion.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2018
The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service staff follow documentation procedures by making annotations in the consults as required by Veterans Health Administration Directive 1232(1), Consult Processes and Procedures, and the Prosthetic and Sensory Aids Service Business Practice Guidelines for Prosthetics Consult Management for power wheelchair and scooter repair.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The OIG recommended the Veterans Integrated Service Network 7 Director implement controls to ensure Prosthetic Service staff monitor and follow up on repairs from initial request through completion to ensure the repairs are timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service managers and staff monitor vendors to ensure they meet agreed-upon delivery dates for repairs.
Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 15
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17-00481-117

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2018
The OIG recommended the Veterans Integrated Service Network 15 Director ensure that staff at all network facilities use the clinically indicated date, when available, when scheduling new patient appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
The OIG recommended the Veterans Health Administration Executive in Charge initiate a process to automate the use of the clinically indicated date, when applicable, when scheduling appointments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2018
The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities appropriately manage the scheduler audit tool in order to conduct the required scheduler audits, communicate specific audit results to scheduling staff, and take corrective actions as needed based on audit results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2018
The OIG recommended the Veterans Integrated Service Network 15 Director examine processes to improve monitoring and tracking for timely surveillance colonoscopies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2018
The OIG recommended the Veterans Integrated Service Network 15 Director implement additional standard monitoring procedures sufficient to enable network facility staff to accurately manage the aging of all referrals for eligible veterans for Choice care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2018
The OIG recommended the Veterans Health Administration Executive in Charge implement standard monitoring procedures to ensure medical appointment timeliness standards are met as required under Choice contracts.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The OIG recommended the Veterans Health Administration Executive in Charge implement controls to ensure Choice medical documentation is received timely in accordance with Choice contracts.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2018
The OIG recommended the Veterans Integrated Service Network 15 Director communicate specific audit results of VHA’s audit of consults to all network facility staff involved in consult management, implement specific training, and ensure corrective action is taken as needed.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2019
The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities manage consults that are clinically indicated for the future in accordance with VHA’s consult policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2018
The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities implement contingency plans in accordance with VHA’s outpatient clinic practice management policy and communicate to providers regarding how to process consults when a service becomes unavailable.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
The OIG recommended the Veterans Integrated Service Network 15 Director ensure the care of patients identified in the patient summaries of this report are evaluated, take action, if appropriate, and confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
Healthcare Inspection – Mismanagement of Resuscitation and Other Concerns at the Buffalo VA Medical Center, Buffalo, New York
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17-01485-128

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 9/16/2019
We recommended that the VA Office of the General Counsel, pursuant to VA Directive 6311, work in conjunction with the Office of Information Technology, Veterans Health Administration offices, and other interested offices to advise the Under Secretary for Health regarding the refinement (or development) of policies reasonably designed to ensure the preservation of electronically stored information when legally necessary (or desirable for purposes of quality improvement), including, but not limited to electronically stored information that is subject to auto-deletion, such as telemetry data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Veterans Integrated Service Network Director conduct an evaluation of the Facility’s quality management practices (including but not limited to Root Cause Analyses, Issue Briefs, Administrative Investigation Boards, and Institutional Disclosures) to ensure that they align with Veterans Health Administration policies and also address the following specific deficiencies in this case: (a) the failure to conduct a Root Cause Analysis, (b) the failure to conduct a timely Administrative Investigation Board, (c) the failure to provide an Issue Brief, (d) the failure of the Administrative Investigation Board to consider all available evidence, and (e) the failure to make an Institutional Disclosure consistent with Veterans Health Administration Policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2018
We recommended that the Facility Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure that staff conduct interprofessional mock code training throughout the Facility with debriefing and monitor outcomes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director conduct an evaluation inclusive of, but not limited to, unit 9B and the Respiratory Department to determine if there are issues undermining teamwork at the work place, take action to address those issues, and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure that staff adhere to the Facility’s telemetry policy including, but not limited to, saving rhythm strips when a patient has a change in his/her baseline or a significant arrhythmia, that a competent staff member is always at the telemetry station, and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure that the Facility’s Education Department staff review the adequacy of its annual telemetry monitoring re-certification process including, but not limited to, evaluating whether to institute additional requirements for staff who rarely have practical experience in telemetry monitoring and establishing procedures to ensure that re-tests are conducted and tracked appropriately and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director evaluate the Respiratory Department handoff communications process including the timing of patients’ treatments and code status and modify as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure staff assess patients before and after breathing treatments, document the patient’s response in the electronic health record, and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2018
We recommended that the Facility Director review the content of Facility staff’s communication to the patient’s family and take corrective action if it is determined that the communication was insufficient to convey that the Facility was disclosing potentially inadequate care.
Healthcare Inspection – Alleged Patient Aligned Care Team Wait Time and Funding Issues at the Monterey Community Based Outpatient Clinic, VA Palo Alto Health Care System, Palo Alto, California
|
17-02686-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that the System Director review human resources and clinic hiring processes for Patient Aligned Care Team staff and take action to minimize delays in filling vacancies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
We recommended that the System Director assess and ensure patient panel sizes for Patient Aligned Care Team providers are in compliance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that the System Director ensure that Patient Aligned Care Team process improvement projects do not negatively affect clinic patient appointments.
Critical Deficiencies at the Washington DC VAMC
|
17-02644-130

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The Medical Center Director ensures that necessary supplies, instruments, and equipment are available in patient care areas at the Medical Center when and where they are needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2019
The Medical Center Director requires operating room staff to conduct the final validation that all supplies, instruments, and equipment needed to perform the planned procedure and to address potential complications are in the operating room and available for use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2019
The Medical Center Director makes certain that the OR staff have accurate lists of surgical instruments needed for particular procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2019
The Under Secretary for Health specifies criteria under which individual medical centers will conduct wild card Aggregated Reviews for high-frequency patient safety events.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Medical Center Director ensures that routine audits of incident reporting system entries are completed to ascertain that all patient safety events are in the National Center for Patient Safety database as required by VHA policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Medical Center Director requires Medical Center oversight committees to follow up and initiate action as necessary on quality assurance matters related to supplies, instruments, or equipment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The Medical Center Director confirms the full utilization of a VHA authorized inventory system that contains accurate and reliable information regarding the availability of supplies throughout the Medical Center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Medical Center Director makes certain that the environmental integrity of clean/sterile storerooms complies with VHA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2019
The Medical Center Director ensures there are clearly defined and effective procedures for replacing missing or broken instruments, and that staff responsible for this function have been educated on the process.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Medical Center Director confirms that clearly defined and effective procedures address the disposition of discolored instruments during reprocessing and that staff responsible for this function have been educated on the process.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Medical Center Director ensures that the Sterile Processing Service (SPS) implements a quality assurance program to verify the cleanliness, functionality, and completeness of instrument sets prior to their reaching clinical areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2019
The Medical Center Director makes certain that SPS and OR personnel comply with policies and procedures for the proper reprocessing of loaner instruments and trays.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director verifies that SPS managers maintain an accurate Master List for reusable medical equipment and file copies of manufacturer’s instructions as required by VHA policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Medical Center Director ensures that the SPS maintains updated and readily accessible standard operating procedures for all instruments and equipment within SPS and its satellite areas in accordance with VHA policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2019
The Medical Center Director verifies that all SPS employees have appropriate, updated competencies and a demonstrated proficiency to perform their assigned duties.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The VISN 5 Director secures adequate space and funding for the Medical Center satellite reprocessing areas, which includes separate decontamination, processing, and packaging areas in accordance with VHA SPS policies.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2018
The VISN 5 Director makes certain that the Medical Center Director resolves open and pending prosthetic consults and implements a plan to address future prosthetic consults in accordance with VHA policy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director ensures the revision of Medical Center Fiscal Service practices to eliminate unnecessary cessations of prosthetic device purchasing, including at fiscal year-end.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The VISN 5 Director, together with Medical Center leaders, develops a staffing plan to fill vacancies that includes accurate numbers of authorized positions by service that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2019
The VISN 5 Director ensures the timely completion of hiring actions at the Medical Center until staffing deficiencies in Logistics Service and Sterile Processing Services are fully resolved.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2019
The Medical Center Director transitions purchase cards held by clinical staff and used for expendable medical supplies to Logistics Service staff, while ensuring that medical supplies can be obtained in a timely manner.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2019
The Medical Center Director ensures that medical supply items are added to the prime vendor formulary in order to meet prime vendor purchasing goals.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2019
The Medical Center Director makes certain that the Purchase Card Coordinator and approving officials monitor the issuance and future use of government purchase cards in accordance with VA Financial Policy.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2018
The Medical Center Director maintains segregation of duties between personnel who order and purchase expendable and nonexpendable items and those who receive the items.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The VISN 5 Director ensures that the Medical Center updates and maintains the Equipment Inventory List (EIL) as required by VA policy and makes certain that the Medical Center Director and Chief Logistics Officer are held accountable for the timely and accurate reporting of the Medical Center EIL.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director ensures that equipment is accurately and timely entered into the Automated Engineering Management System/Medical Equipment Reporting System.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2019
The Medical Center Director ensures that unrequired equipment is turned in for disposition consistent with VHA policies and procedures
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director properly secures all areas used to store medical equipment and supplies.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2019
The Medical Center Director designates an official records manager, alternate records manager, and official records liaisons, as well as implements a records management program in accordance with the National Archives and Records Administration requirements.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director verifies that actions have been taken to notify patients when their information may have been improperly accessed, as appropriate.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The Medical Center Director verifies that accurate and complete financial documentation to support medical supply and equipment purchases is readily available in accordance with GAO Standards for Internal Control in the Federal Government.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The VISN 5 Director audits a representative sample of FY 2017 Medical Center supply, instrument, and equipment purchases and ensures adequate internal controls for future purchases are in place.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The Deputy Under Secretary for Health for Operations and Management ensures that the VHA Procurement and Logistics Office conducts regular audits of the logistics services within VHA medical centers to assess compliance with VA and VHA policies pertaining to procurement and logistics, and makes certain that timely and effective remediation occurs in response to all noncompliant conditions identified as a result of those audits.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The VISN 5 Director evaluates the accuracy of representations made by Medical Center staff in connection with the completion of action plans arising out of the National Program Office of Sterile Processing October 2016 site visit and determines whether administrative actions should be taken as a result of those representations.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2019
The VISN 5 Director institutes procedures designed to ensure the accuracy of future representations made by Washington DC VA Medical Center staff in connection with action plans submitted to oversight bodies such as VHA program offices.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Under Secretary for Health clearly defines program offices’ responsibility for reporting high-priority recommendations to responsible individuals within VHACO, and requires independent verification that the relevant medical center and/or VISN have implemented the recommendations.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2018
The Under Secretary for Health develops a means of aggregating and analyzing available data on Logistics, Sterile Processing, Prosthetics, and Human Resources services (or other services as the Under Secretary for Health deems appropriate) so that major operational deficiencies at a medical center or VISN that affect multiple services or functions may be detected and corrected.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2019
The Under Secretary for Health takes appropriate administrative action to address the conditions identified in this report.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The VISN 5 Director oversees implementation of recommendations directed to the Medical Center Director.
No. 40
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The Under Secretary for Health verifies the successful implementation of all recommendations contained within this report.
Audit of Interior Design and Furnishing Contract Mismanagement by Network Contracting Office 21
|
16-00409-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
The OIG recommended Service Area Office West Executive Director ensure the Network Contracting Office 21 Director implements the required integrated oversight process to perform the required pre-award contract reviews to ensure contracting officers’ compliance with Federal and VA acquisition regulations prior to contract award.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
The OIG recommended the Veterans Integrated Service Network 21 Director consult with the appropriate VA financial and legal officials to determine steps the Northern California Health Care System Director should take to remedy the violation of the bona fide needs rule.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2018
The OIG recommended the Service Area Office West Executive Directortake steps to ensure the Network Contracting Office 21 Director developand implement processes to effectively monitor the status of contractsand ensure contracting officers appropriately modify the contracts orclose them out in accordance with contract terms and the FederalAcquisition Regulation.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,300,000.00
Healthcare Inspection—Quality of Care and Patient Safety Concerns in the Community Living Center, James A. Haley VA Hospital, Tampa, Florida
|
17-01491-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2018
We recommended that the Facility Director ensure that Community Living Center and Emergency Department staff understand and comply with policies for communication about residents requiring evaluation and treatment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that the Facility Director ensure that Community Living Center leaders develop a system to ensure fall precautions identified in the Falls Assessment are consistently reflected in the Individual Care Plan and implemented accordingly, and that staff are held accountable.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended that the Facility Director ensure the availability and functionality of fall prevention and safety devices such as hip protectors and chair alarms.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that the Facility Director ensure that Community Living Center leaders follow through on efforts to determine staff knowledge deficits related to fall prevention and institute training and process improvements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended that the Facility Director ensure that Community Living Center leaders conduct appropriate reviews and implement required actions in cases of suspected abuse or neglect.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended that the Facility Director ensure an adequate nurse staffing mix to meet the acuity levels and needs of the Community Living Center’s residents.
Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
|
17-01746-116

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: 12/10/2018
The Facility Director ensures that a senior-level committee is established and responsible for key Quality, Safety, and Value functions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Facility Director ensures the Patient Safety Manager completes the required minimum of eight root cause analyses each fiscal year and monitors the manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Chief of Staff ensures that anticoagulation management program quality assurance data are analyzed and reported to the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians' compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Chief of Staff ensures clinicians consistently obtain and document all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians' compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Chief of Staff ensures all required elements specific to anticoagulation management are included in competency assessments for employees actively involved in the anticoagulant program and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Associate Director ensures environment of care inspections are conducted at the required frequency and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Chief of Staff and the Nurse Executive ensure that the Community Nursing Home Oversight Committee includes representation by all required disciplines and monitor compliance
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Nurse Executive ensures social workers conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitors social workers’ compliance.
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