All Reports

Comprehensive Healthcare Inspection Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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18-01147-47

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: 3/30/2020
The Chief of Staff ensures Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
The Facility Director ensures that Controlled Substances Inspection program staff have no access to or involvement in drug procurement, prescribing, or dispensing, or administration of controlled substances and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
The Facility Director ensures that Controlled Substances Inspectors perform reconciliation of controlled substance returns to pharmacy stock from every automated dispensing cabinet and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
The Facility Director ensures that Controlled Substances Inspectors verify there is a corresponding sealed evidence bag containing drug(s) for each medication listed on the “Destructions File Holding Report” during monthly inspections and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Durham VA Medical Center, North Carolina
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18-01146-35

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The Chief of Staff ensures that Executive Council of Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion to recommend approval of clinical privileges for LIPs and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2019
The Facility Director ensures Controlled Substances Inspectors complete monthly pharmacy prescription pad inventories and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky
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18-01163-36

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Facility Director ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Facility Director ensures the Patient Safety Manager or designee provides feedback to employees or departments who submit patient safety incidents that result in root cause analysis and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Chief of Staff ensures Focused and Ongoing Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and Fort Knox Community Based Outpatient Clinic and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Associate Director ensures staff assigned to conduct mental health environment of care inspections use the Mental Health Environment of Care Checklist to identify and correct deficiencies in a timely manner and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The Associate Director ensures the Facility’s Emergency Operations Plan includes required elements and that the annual review of inventory and assets is conducted and documented and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Facility Director ensures that all deficiencies identified on the annual physical security survey are addressed and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Delay in Care and Care Coordination at Cheyenne VA Medical Center, Wyoming, and Iowa City VA Health Care System, Iowa
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18-00693-41

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Cheyenne VA Medical Center Director ensures timely surveillance for cancer patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Cheyenne VA Medical Center Director improves processes for care coordination and communication between Cheyenne VA Medical Center providers and non-VA providers for cancer patients.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2020
The Cheyenne VA Medical Center Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Cheyenne VA Medical Center Director confers with the Office of Chief Counsel in accordance with Veterans Health Administration Handbook 1004.08 regarding institutional disclosures and takes action as necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Cheyenne VA Medical Center Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Iowa City VA Health Care System Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Iowa City VA Health Care System Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.
Delays in the Processing of Survivors' and Dependents' Educational Assistance Program Benefits Led to Duplicate Payments
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18-01278-13

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/8/2019
The OIG recommended the Under Secretary for Benefits direct Compensation Service and Office of Field Operations to develop and implement processes and procedures that ensure monitoring of Survivors’ and Dependents’ Educational Assistance electronic mailboxes and timely establishment of compensation adjustments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2019
The OIG recommended the Under Secretary for Benefits direct Education Service to develop and implement an effective process to ensure receipt of Survivors’ and Dependents’ Educational Assistance benefit notifications by VA Regional Office staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2019
The OIG recommended the Under Secretary for Benefits ensure Compensation Service and Education Service develop electronic system functionality to identify cases with potential duplication of benefits when a dependent begins receiving Survivors’ and Dependents’ Educational Assistance payments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2019
The OIG recommended the Under Secretary for Benefits ensure the National Work Queue and Compensation Service assign cases with compensation adjustments to remove the school child allowance as soon as the cases are ready for processing.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/8/2019
The OIG recommended the Under Secretary for Benefits ensure Office of Field Operations takes prompt action to adjust benefits for cases in the OIG sample in which payment duplications had not been identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 22,500,000.00
Comprehensive Healthcare Inspection Program Review of the Iowa City VA Health Care System, Iowa
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18-01157-31

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2019
The Chief of Staff ensures service chiefs complete all required elements, including specialty-specific criteria, for Ongoing Professional Practice Evaluations and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2019
The Facility Director ensures that controlled substances program staff complete reconciliation of controlled substances returns to pharmacy stock during controlled substance inspections and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2019
The Chief of Staff ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board or council and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the West Palm Beach VA Medical Center, Florida
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18-01159-38

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Chief of Staff ensures that clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2019
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Director ensures implementation of root cause analysis actions and feedback of results to the reporting individuals or departments and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Chief of Staff ensures that service chiefs complete required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Chief of Staff ensures the service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Associate Director ensures all staff are educated on how to access safety data sheet information and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Associate Director ensures the Port Saint Lucie Community Based Outpatient Clinic panic alarms are functional and regularly tested and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Pittsburgh Healthcare System, Pennsylvania
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18-01154-27

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Chief of Staff ensures that the Medical Executive Board uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Chief of Staff ensures service chiefs complete all required elements, including minimum required specialty criteria for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Deputy Director ensures that a safe and clean environment is maintained throughout the Facility and Westmoreland County Community Based Outpatient Clinic and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Deputy Director ensures the flooring in the mental health seclusion rooms provides cushioning.
Inadequate Governance of the VA Police Program at Medical Facilities
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17-01007-01

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No. 1
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Clarify program responsibilities between the Veterans Health Administration and theOffice of Operations, Security, and Preparedness, and evaluate the need for a centralizedmanagement entity for the security and law enforcement program across all medicalfacilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/16/2022
Ensure police staffing models are implemented for determining facility-appropriate levelsfor officers at medical facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2021
Make certain medical facilities use strategies to address police staffing challenges such ashaving documented recruitment plans for police officer positions that include adetermination of the need for special salary rates and incentives.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/11/2024

Assess the staffing levels for the Office of Security and Law Enforcement policeinspection program, and authorize and provide sufficient resources to conduct timelyinspections of police units at medical facilities to help identify program complianceissues.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/3/2021
Ensure procedures are developed for appropriately handling VA police investigations of medical facility leaders.
Provider Assignment and Dermatology Consult Scheduling Delays at the Joint Ambulatory Care Center, Pensacola, Florida
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17-02163-23

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2019
The Gulf Coast Veterans Health Care System Director ensures that patients are assigned primary care providers, as required by Veterans Health Administration policy, and that the assignments are monitored for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Gulf Coast Veterans Health System Director ensures that patients with Joint Ambulatory Care Center dermatology consults are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult timeframe, and that the scheduling process is monitored for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Gulf Coast Veterans Health Care System Director ensures that system managers review dermatology and non-VA care scheduling staffing levels, and develop an action plan to address recommendations, if any, from the staffing level reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2019
The Gulf Coast Veterans Health System Director takes appropriate action as related to Patient B’s physicians’ improper electronic health record documentation as discussed in this report.
Comprehensive Healthcare Inspection Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
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18-01142-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Chief of Staff ensures that service chiefs communicate to the Peer Review Committee the completion of individual improvement actions and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Chief of Staff ensures that all Focused Professional Practice Evaluations include clearly delineated timeframes and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Associate Director ensures that staff store clean and dirty equipment separately and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2018
The Associate Director ensures the mental health unit seclusion room toilet is shatterproof.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Associate Director ensures that environment of care rounds are conducted as required at the McComb Community Based Outpatient Clinic and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Associate Director ensures that staff at the McComb Community Based Outpatient Clinic remove all expired, damaged, and/or contaminated medications and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Associate Director ensures the McComb Community Based Outpatient Clinic managers maintain a safe and clean environment and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Associate Director ensures that shelving is clean and bottom storage shelves are solid at the McComb Community Based Outpatient Clinic and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2019
The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive posttraumatic stress disorder screens and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2019
The Chief of Staff ensures that acceptable providers offer and refer patients with positive posttraumatic stress disorder screens for further diagnostic evaluations and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington
|
18-01144-24

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2019
The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from social work and the Chief Business Office revenue utilization review and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2019
The Chief of Staff ensures Ongoing Professional Practice Evaluations utilize assessments by providers with similar training and privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2019
The Associate Director ensures managers clearly mark and securely store medical biohazardous waste and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2019
The Associate Director ensures the Police and Security Operations document response time to panic alarm testing at the locked mental health unit and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2019
The Associate Director ensures that the Emergency Management Plan is reviewed annually and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2019
The Facility Director ensures that the Quality Council maintains oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2018
The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada
|
18-01145-26

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Associate Director ensures the VA Police regularly test panic alarms at the Northwest Las Vegas VA Clinic and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing in the locked mental health unit and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The Facility Director ensures controlled substance monthly inspection dates are randomly selected to avoid distinguishable patterns and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The Facility Director ensures that controlled substances inspectors perform reconciliation of controlled substance refills to automated dispensing cabinets in patient care areas and returns to pharmacy stock and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The Facility Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2019
The Facility Director ensures that Geriatrics and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
VA’s Oversight of State Approving Agency Program Monitoring for Post-9/11 GI Bill Students
|
16-00862-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/8/2019
The Under Secretary for Benefits negotiates an amendment to State Approving Agency contracts to clarify requirements for program approvals and require, subject to the availability of resources, quarterly samples and reviews and evaluations of supporting documentation for State Approving Agency approvals to ensure approved programs meet Title 38 of the United States Code requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/8/2019
The Under Secretary for Benefits negotiates amendments to State Approving Agency contracts that, subject to available resources, require the State Approving Agencies to periodically reapprove programs and evaluate program changes and other operational changes, such as advertisement practices, that may affect a program’s continued eligibility and compliance with Title 38 of the United States Code.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/2/2019
The Under Secretary for Benefits refers schools identified during the audit with potentially erroneous, deceptive, or misleading advertising practices to the Federal Trade Commission for it to decide whether any further reviews or actions are needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/8/2019
The Under Secretary for Benefits revises and strengthens compliance surveys to improve the assessment of program eligibility and compliance survey quality reviews to include the review of supporting documentation and an independent assessment of the quality of the completed compliance surveys.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/8/2019
The Under Secretary for Benefits negotiates an amendment to the State Approving Agency contracts to establish quality assurance metrics and ensure the Veterans Benefits Administration collects and uses quality assurance data from its reviews of the State Approving Agencies’ approvals, monitoring, and compliance surveys in its annual evaluations of the State Approving Agencies.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/8/2019
The Under Secretary for Benefits assesses whether funding for State Approving Agencies is sufficient to ensure the adequate review, approval, and monitoring of programs, in conjunction with the establishment of a contract to update the State Approving Agency funding allocation model.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,300,000,000.00
Comprehensive Healthcare Inspection Program Review of the Central Texas Veterans Health Care System, Temple, Texas
|
18-01137-15

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2019
The Chief of Staff ensures Service Chiefs include clearly delineated timeframes in practitioners’ Focused Professional Practice Evaluation competency reviews and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2019
The Chief of Staff ensures Service Chiefs present the results of completed Focused Professional Practice Evaluations to the Medical Staff Executive Council to recommend continuing the initially granted privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Chief of Staff ensures Service Chiefs include service-specific data in Ongoing Professional Practice Evaluations and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Chief of Staff ensures that the Chief, Pathology and Laboratory Medicine Service, includes the required pathology-specific criteria, as applicable, in pathology practitioners’ Ongoing Professional Practice Evaluations and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Associate Director ensures personal protective equipment is readily accessible and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2019
The Assistant Director–Waco ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2019
The Associate Director and Assistant Director–Austin ensure that prescribed sleep apnea equipment is furnished timely to patients and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Associate Director ensures VA Police and Security Service regularly test panic alarms and take follow-up actions for identified deficiencies at the Austin Community Based Outpatient Clinic and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Associate Director ensures VA Police and Security Service regularly test panic alarms and take follow-up actions for identified deficiencies at the Waco campus locked mental health unit and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2019
The Assistant Director–Waco ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Facility Director ensures that the Controlled Substance Coordinator completes monthly summary of findings and quarterly trend reports and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Facility Director ensures that Controlled Substances Inspectors are appointed in writing prior to performing inspector duties and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Facility Director ensures that Controlled Substances Inspectors verify drugs held for destruction during monthly inspections at the Waco inpatient pharmacy and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Facility Director ensures Controlled Substances Inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections at the Waco outpatient pharmacy and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Facility Director ensures that Controlled Substances Inspectors verify evidence of written prescriptions for non-electronic controlled substance orders during monthly area inspections at the Temple outpatient pharmacy and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2019
The Chief of Staff ensures providers or designees communicate mammogram results to patients and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2019
The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Maine Healthcare System, Augusta, Maine
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18-01152-14

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: 3/27/2019
The Facility Director ensures the Patient Safety Manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that the Clinical Executive Board reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the Facility Director and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The Chief of Staff ensures that clinical managers complete all required elements for Focused Professional Practice Evaluations for the determination of practitioners’ privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2020
The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2019
The Associate Director ensures all staff are educated on how to access safety data sheet information and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2019
The Facility Director ensures that Controlled Substance Inspectors conduct monthly controlled substance inspections and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Associate Director ensures that geriatric evaluation performance improvement activities are reviewed by a Facility leadership board and monitors compliance.
Patient and Radiation Safety Concerns at the John D. Dingell VA Medical Center, Detroit, Michigan
|
18-02210-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The John D. Dingell VA Medical Center Director ensures that radiologic equipment receives the required inspection and testing by a qualified medical physicist, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The John D. Dingell VA Medical Center Director ensures providers and radiology technicians complete fluoroscopy training as required, and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The John D. Dingell VA Medical Center Director ensures clinical privileges are granted in accordance with policy, and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The John D. Dingell VA Medical Center Director ensures that the radiology department conform to radiation safety standards as outlined through the National Health Physics Program and fully address any recommendations and violations, and monitors to completion.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The John D. Dingell VA Medical Center Director ensures that the Radiation Safety Committee minutes reflect actions taken to address National Health Physics Program recommendations and violations, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The John D. Dingell VA Medical Center Director ensures that the Radiation Safety Officer and Radiation Safety Committee initiate and utilize the Veterans Health Administration required tracking matrix to track unresolved action items to completion, and monitors compliance.
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