All Reports

Comprehensive Healthcare Inspection Program Review of the Dayton VA Medical Center, Ohio
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18-00619-242

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: 1/24/2019
The Chief of Staff ensures that the assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews 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 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: 7/22/2019
The Chief of Staff ensures that the interdisciplinary group review UM data on an ongoing basis and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that Service Chiefs complete all 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: 7/22/2019
The Associate Director ensures environment of care rounds are conducted in all areas of the Facility at the required frequency and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Associate Director ensures that Facility managers maintain a safe and clean environment throughout 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 all medical equipment is identified as safe for patient use and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that geriatric evaluation performance improvement activities are conducted, documented, and reviewed by an appropriate leadership board and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2020
The Chief of Staff ensures providers perform geriatric medical evaluations and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Chief of Staff ensures that clinicians accurately identify and implement geriatric evaluation plan of care interventions and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Beckley VA Medical Center, West Virginia
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17-05401-240

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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 that service line managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Chief of Staff ensures that service line managers collect Ongoing Professional Practice Evaluation data utilizing 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: 4/23/2019
The Associate Director ensures environment of care rounds are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2019
The Associate Director ensures required team members participate on environment of care rounds and that attendance is recorded in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2018
The Facility Director ensures that deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2019
The Facility Director ensures that the controlled substances inspectors consistently perform controlled substances order verification as required and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Chief of Staff ensures that mammogram results are electronically linked to the radiology orders and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2019
The Associate Director for Patient Care Services ensures that nursing staff 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 Tomah VA Medical Center, Wisconsin
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17-05400-246

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2018
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Chillicothe VA Medical Center, Ohio
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18-01012-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Chief of Staff ensures practitioners’ Focused Professional Practice Evaluations include clearly delineated timeframes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Misuse of Time and Resources within the Veterans Engineering Resource Center in Indianapolis, Indiana
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17-04156-234

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 1.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 2.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 3.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against other OSI VERC employees identified by the OIG for misusing government time and resources associated with this endeavor.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2019
The Principal Deputy Under Secretary assesses the adequacy of oversight and training for OSI VERC employees regarding the appropriate use of VA time and resources and addresses any deficiencies.
Review of Two Mental Health Patients Who Died by Suicide, William S. Middleton Memorial Veterans Hospital Madison, Wisconsin
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17-02643-239

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Facility Director expands the Facility’s Root Cause Analysis of Patient 1’s death to include interviews of all key staff by individuals who are not their supervisors; and if additional deficiencies are identified, ensures that Facility managers complete an action plan and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Veterans Integrated Service Network Director ensures that the Facility Director consult with the Office of Chief Counsel regarding Patient 1 and Patient 2 whether an institutional disclosure is appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Veterans Integrated Service Network Director ensures an ethics review is completed regarding Patient 1’s participation in the research study and provision of guidance on the voluntary participation of patients under court treatment mandates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Facility Director strengthens processes to ensure that timely notification to county monitoring agencies occurs in cases of court Settlement Agreement violations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Facility Director strengthens processes to ensure that Facility staff speak directly with and notify the county monitoring agency staff before an inpatient with a court Settlement Agreement is discharged.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2018
The Facility Director revises the mental health inpatient unit policy to include family notification with patient consent in discharge planning and ensures that Facility policy is consistent with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director strengthens processes to ensure that mental health clinical assessments are complete and comprehensive to include a symptom inventory and severity assessment, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director strengthens processes to ensure that prescribers are prescribing psychiatric medications safely including adherence to the black box warnings, and that managers complete electronic health record reviews to monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2019
The Facility Director ensures the development of a methodology for the assignment of psychiatrists as prescribers for patients with complex mental health care needs, including patients flagged as high-risk for suicide.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director strengthens the Ongoing Professional Practice Evaluation process to ensure that psychiatric clinical pharmacists practice within their scope of practice, and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director ensures the development of a collaborative agreement and/or policy to address specific conditions that require oversight of psychiatric clinical pharmacists by psychiatrists in the Mental Health Service.
Comprehensive Healthcare Inspection Program Review of the VA Palo Alto Health Care System, California
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18-00617-227

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that the Patient Safety Manager reports and documents all patient safety incidents using the Joint Patient Safety Reporting System and monitors the Patient Safety Manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that the Patient Safety Manager submits annual reports to the leadership team for review and monitors the Patient Safety Manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Associate Director ensures the VA Police test panic alarms at the San Jose community based outpatient clinic regularly and monitors VA Police compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that controlled substances inspectors complete monthly inspections of assigned areas and that controlled substances coordinators refrain from conducting routine inspections, and the Facility Director monitors program inspectors’ and coordinators’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Chief of Staff ensures that the geriatric evaluation program quality improvement data are reviewed and reported to the Quality, Safety and Value Council and monitors compliance.
Alleged Split Purchases at the VA St. Louis Health Care System
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16-02863-199

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2018
The Health Care System Director submits ratification requests to the Veterans Health Administration’s Head of Contracting Activity for the split purchases and the purchases that exceeded the micropurchase threshold identified in the OIG report for calendar years 2014 and 2015.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2018
The Health Care System Director provides additional training for purchase cardholders and approving officials focused on avoiding split purchases and complying with micropurchase thresholds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Health Care System Director establishes a rigorous monitoring mechanism to ensure management controls are in place and working to identify and prevent improper purchase card transactions.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 564,000.00
Unwarranted Medical Reexaminations for Disability Benefits
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17-04966-201

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2022
The Under Secretary for Benefits establishes internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modifies VBA procedures as appropriate to reflect these improved business processes.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2019
The Under Secretary for Benefits takes steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2019
The Under Secretary for Benefits enhances VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and categorize unwarranted reexaminations as errors.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2022
The Under Secretary for Benefits conducts a special focused quality improvement review of cases with unwarranted reexaminations to develop data sufficient to understand and redress the causes of any avoidable errors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 100,600,000.00
Supervision and Care of a Residential Treatment Program Patient at a Veterans Integrated Service Network 10 Medical Facility
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16-03137-208

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2019
The Facility Director ensures that Facility managers coordinate and implement uniform Program policies and procedures relating to supervision of patients, and that Facility staff consistently follow those policies and procedures.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Facility Director ensures that the Mental Health Treatment Coordinator and interdisciplinary team develop and document the interdisciplinary treatment plan, as required by Veterans Health Administration and Facility policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2018
The Facility Director ensures that the Program offers patient treatment, daily, as required by Veterans Health Administration.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2018
The Facility Director ensures that Program managers regularly evaluate restrictions to patient privileges and methods to reinstate restricted or lost patient privileges, as required by Veterans Health Administration.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2018
The Facility Director ensures that staff document Program patient care in the electronic health record within Veterans Health Administration and Facility requirements and timeframes.
Comprehensive Healthcare Inspection Program Review of the VA San Diego Healthcare System
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18-00616-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific performance data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2018
The Associate Director and Assistant Director ensure required team members consistently participate on environment of care rounds and monitor team members’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Assistant Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
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 and infection prevention education and monitors nurses’ compliance.
Alleged Inappropriate Controlled Substance Prescribing Practices at a Veterans Integrated Service Network 20 Medical Facility
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16-05323-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
Veterans Integrated Service Network 20 Director conducts a management review of the care of the patient who is the subject of this report, and confers with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The Facility Director implements a systematic approach to review prescribing of controlled substances to individuals at high-risk for substance abuse or misuse.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The Facility Director strengthens processes that foster interdisciplinary collaboration for the management of patients with complex clinical pain and allows referrals from all Facility staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that policy and practice is consistent with Veterans Health Administration Directive 1005, Informed Consent for Long-term Opioid Therapy for Pain.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The Facility Director ensures provider accountability for compliance with Veterans Health Administration and Facility controlled substance policies, including opioid informed consent policies.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Facility Director strengthens the Facility Board that is responsible for controlled substances safety, including clarification of roles, responsibilities, and authority; and the development of clearly written definitions and entry criteria for Category II patient record flags in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director maintains full compliance with the Veterans Health Administration’s peer review directive, including but not limited to the selection of impartial reviewers and removing the service chief level review from the Facility peer review process.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director performs a focused professional practice evaluation on primary care provider 1’s opioid prescribing practices in high-risk patients.
Alleged Inappropriate Anesthesia Practices at the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania
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16-00284-214

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The James E. Van Zandt VA Medical Center Director ensures that the James E. Van Zandt VA Medical Center’s anesthesia needs and services are evaluated and align with Veterans Health Administration and James E. Van Zandt VA Medical Center policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2018
The James E. Van Zandt VA Medical Center Director ensures that service chief provider oversight includes facility-specific privileges and provider-specific Ongoing Professional Practice Evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2018
The James E. Van Zandt VA Medical Center Director ensures that James E. Van Zandt VA Medical Center leaders consult with the Office of Chief Counsel to determine if the anesthesiologist should be reported to the National Practitioner Data Bank and the State Licensing Board for administrating medications inconsistent with the Food and Drug Administration approved manufacturer’s instructions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The James E. Van Zandt VA Medical Center Director ensures that the Patient Advocate enters all patient complaints into the Patient Advocate Tracking Systems database; documents issue descriptions and actions taken; and tracks all complaints to resolution.
Patient Overdose Death in a Residential Rehabilitation Treatment Program at a VISN 1 Medical Facility
|
17-04354-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The VISN 1 Medical Facility Director ensures that staff receive education about the process for initiating Medication Assisted Therapy for patients enrolled in the Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The VISN 1 Medical Facility Director ensures that a standard operating procedure is issued to effectively track patients enrolled in the Program who fail to show for appointments at off-site substance abuse day programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The VISN 1 Medical Facility Director ensures that all appropriate staff receive training regarding the standard operating procedure for tracking patients enrolled in the Program who fail to show for appointments in at off-site substance abuse day programs.
VA Southern Nevada Healthcare System's Alleged Unnecessary Use of Outside Vendors to Purchase Prosthetics
|
16-02247-165

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 21 Director ensures the Director of the VA Southern Nevada Healthcare System develops and implements effective processes such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetics Laboratory operates in a manner that maximizes its personnel and on hand inventory to provide veterans with timely and cost effective fitting services for compression garments and orthotic shoes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 22 Director ensures the VA San Diego Healthcare System Director takes steps such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetic Service operates in a manner that maximizes its resources to provide veterans with timely and cost effective fitting services compression garments and orthotic shoes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements effective processes to monitor purchasing employees’ usage of all non item Healthcare Common Procedure Coding System codes to ensure the proper utilization of these codes.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements a process to examine the 4,530 consults closed, but not cloned, by purchasing employees using the NR018 code from October 2014 through May 2016 and take necessary action to ensure veterans received their prescribed prosthetic or orthotic item(s).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 242,000.00
Comprehensive Healthcare Inspection Program Review of the VA Hudson Valley Health Care System, Montrose, New York
|
17-05399-194

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Chief of Staff ensures that Facility clinical managers consistently initiate Focused Professional Practice Evaluations and that they 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: 11/15/2018
The Associate Director ensures all required team members consistently participate on environment of care rounds and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Associate Director ensures damaged or soiled furnishings and equipment in patient care areas are sanitized, repaired, or removed from service and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2018
The Associate Director ensures that shower soap dispensers in the acute Mental Health Unit are replaced as required by the Mental Health Environment of Care Checklist and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Facility Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Memphis VA Medical Center
|
18-00609-185

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Facility Director ensures Facility staff enter all patient incidents into WebSPOT or the VHA Patient Safety Information System and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired Licensed Independent Providers and monitors compliance
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Chief of Staff ensures that service chiefs include review of relevant data in Ongoing Professional Practice Evaluations to determine continuation of current privileging for Licensed Independent Providers and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2019
The Associate Director ensures Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Associate Director ensures that bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2019
The Associate Director ensures clinical staff remove expired medications from patient care areas and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2019
The Associate Director ensures the Facility managers maintain a safe and clean environment at the Covington North Community Based Outpatient Clinic and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Associate Director ensures that Community Based Outpatient Clinic staff maintain clear means of egress at the Covington North Community Based Outpatient Clinic and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Associate Director ensures that environmental management service staff maintain clean air ducts and ventilation grills in food service and storage areas and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Facility Director ensures the Controlled Substance Coordinator completes and documents annual controlled substance inspector training and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2019
The Chief of Staff ensures that Geriatric and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Associate Director for Patient Care Services ensures that all staff involved in managing central lines receive central line-associated bloodstream infection prevention education and monitors compliance.
Alleged Mismanagement of Inpatient Care at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas
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17-02484-189

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
The System Director ensures provider privileges are facility-specific as required by Veterans Health Administration Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The System Director ensures the System’s Bylaws and Rules of the Medical Staff are updated to reflect compatibility and compliance with 38 CFR 17.415, Full Practice Authority for Advance Practice Registered Nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
The System Director ensures the Facility meets the requirements for physician staffing for inpatient coverage, pre-operative risk and anesthesia assessments, and anesthesia services in-house coverage as required by Veterans Health Administration Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex Surgical Procedures, May 6, 2010.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The System Director reviews the timeliness of specialty care consults and ensures that specialty consults are provided timely as required by Veterans Health Administration policy, including the use of service/care coordination agreements as necessary to define time frames.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The System Director ensures the Facility provides a list to the Emergency Department and inpatient staff of appropriate on-call social work and mental health staff, as well as specialty physicians, including radiologists, as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The System Director ensures the Facility provides and monitors the availability and timely response of specialty consultants and ultrasound services in the Emergency Department as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
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