All Reports

Comprehensive Healthcare Inspection Program Review of the VA Puget Sound Health Care System, Seattle, Washington
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18-00334-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2018
The Deputy Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Deputy Director ensures all medical equipment at the South Sound VA Clinic is identified as safe for patient use and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Chief of Staff ensures the Infection Control Committee consistently documents discussions of on-going construction activities and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Assistant Director ensures temperature monitoring occurs in dry food storage areas and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2018
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
Audit of the Beneficiary Travel Program, Special Mode of Transportation, Eligibility and Payment Controls
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15-00022-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure clinicians and Beneficiary Travel Office staff comply with Veterans Health Procedure Guide 1601B.05 eligibility requirements for authorizing Special Mode of Transportation services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health modify Veterans Health Administration Procedure Guide 1601B.05 to require the Beneficiary Travel Office staff to verify beneficiaries attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure VA Medical Centers comply with Veterans Health Administration policies for verifying beneficiaries listed on vendor invoices had been properly authorized for Special Mode of Transportation services or attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health ensure the Improper Payments Elimination and Recovery Act reports provided to Veterans Integrated Service Networks are modified to include Special Mode of Transportation information specific to vendor payments by VA Medical Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The OIG recommended the Under Secretary for Health implement use of Centers for Medicare and Medicaid Services Rates when savings can be achieved for Special Mode of Transportation ambulance services in accordance with 38 U.S.C. Section 111(b)(3)(C).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health implement controls to prevent beneficiaries using Special Mode of Transportation services from also obtaining mileage reimbursement for the same appointment(s).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 173,829,000.00
Alleged Contracting and Appropriation Irregularities at the Office of Transition, Employment, and Economic Impact
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16-04555-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/31/2019
The OIG recommended the Executive in Charge for Benefits coordinate with the Head of VA Contracting Activity and the Office of General Counsel to determine what actions need to be taken to remedy the unauthorized commitment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/7/2018
The OIG recommended the Executive in Charge for Benefits obtain appropriate funding for all future information technology costs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/3/2020
The OIG recommended the Executive in Charge for Benefits coordinate with the Office of Information Technology, the Office of Management, and the Office of General Counsel to make accounting adjustments to debit the information technology account that should have been used and credit the general operating expense account that was inappropriately used, determine whether Antideficiency Act violations occurred, and report the violations as appropriate.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 11,700,000.00
Healthcare Inspection - Testosterone Replacement Therapy Initiation and Follow-Up Evaluation in VA Male Patients
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15-03215-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Under Secretary for Health ensures that providers establish clinical signs and symptoms consistent with androgen deficiency, prior to testing patients’ testosterone level for confirmation in alignment with Veterans Health Administration guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers biochemically confirm hypogonadism through repeated testosterone testing prior to initiation of testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers determine whether the etiology of hypogonadism is primary or secondary, prior to testosterone replacement therapy initiation in alignment with Veterans Health Administration guidance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers discuss and document the risks and benefits of testosterone therapy with patients prior to initiation in alignment with Veterans Health Administration guidance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers assess and document patients’ symptoms improvement and adverse effects within 3–6 months of initiation before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers monitor patients’ hematocrit levels within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Under Secretary for Health ensures that providers assess and document patients’ adherence to therapy and perform testosterone level test within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.
VA’s Federal Information Security Modernization Act Audit for Fiscal Year 2017
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17-01257-136

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all identified weaknesses are incorporated into the Governance Risk and Compliance tool, in a timely manner, and corresponding Plans of Actions and Milestones are developed to track corrective actions and remediation. (This is a repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting on Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated. (This is a modified repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for reviewing and updating key security documents such as risk assessments and security control assessments on an annual basis and ensure the information accurately reflects the current environment. (This is a modified repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement periodic reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully implement two-factor authentication for all network access methods throughout the agency. (This is a repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and web application servers. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology maintain a complete and accurate security baseline configurations for all platforms and ensure all baselines are appropriately implemented for compliance with established VA security standards. (This is a modified repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved network access controls to ensure medical devices and networks, not managed by the Office of Information and Technology, are appropriately segregated from general networks and mission-critical systems. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for ensuring the encryption of backup data prior to transferring the data offsite for storage. (This is a repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved processes for the testing of contingency plans and failover capabilities for critical systems to ensure that all components can be recovered at the assigned sites and within stated timeframes. (This is a modified repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and connections for unauthorized activity. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology ensure that VA’s Network Security and Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans and data exfiltrations from VA networks. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of unauthorized software on agency devices. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/12/2019
We recommended the Executive in Charge for Information and Technology implement improved procedures for overseeing contractor-managed cloud-based systems and ensure information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/11/2018
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating systems inventory, including contractor-managed systems and interfaces, and provide this information in accordance with Federal reporting requirements. (This is a repeat recommendation from prior years.)
Administrative Investigation - Conflict of Interest, Nepotism, and False Statements, VA Office of General Counsel, Washington, DC
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17-03324-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Mr. Fleck.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Ms. KW.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the total amount of funds unlawfully expended to pay for Ms. KW’s salary since her initial VA appointment on January 8, 2017, and ensures that a bill of collection is issued to Ms. KW in that amount.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate corrective action to take concerning Ms. KW’s VA appointment and takes such action.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/6/2019
The VA Deputy Secretary confers with VA’s Designated Agency Ethics Official to ensure Deputy General Counsel for Legal Policy staff members receive appropriate ethics training as related to our findings in this report.
Comprehensive Healthcare Inspection Program Review of the VA North Texas Health Care System, Dallas, Texas
|
17-05404-149

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures practitioners’ Focused Professional Practice Evaluation competency reviews include clearly delineated timeframes and criteria and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the review of service- and practitioner-specific data and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the utilization of service-specific criteria and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Chief of Staff and Associate Director for Patient Care Services ensure personal protective equipment is readily accessible and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and reconciliation of returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
The Chief of Staff ensures ordering providers or designees communicate mammogram results to patients and monitors providers’ compliance.
Review of Research Service Equipment and Facility Management, Eastern Colorado Health Care System
|
16-02742-77

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director establish a policy requiring the Research Service implement a process to identify all accountable equipment annually that does not have a barcode label, and ensure these items are communicated to the Logistics Service so they receive a barcode label and are recorded in the automated inventory system.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The OIG recommended the VA Eastern Colorado Health Care System Director develop an action plan that would ensure all Research Service sensitive information technology equipment is assigned to an information technology equipment inventory list.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
3. The OIG recommended the VA Eastern Colorado Health Care System Director implement a training program to ensure Information Technology, Research, and Logistics Service staffs are properly trained to enable them to identify and place sensitive information technology equipment under control.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2019
The OIG recommended the VA Eastern Colorado Health Care System Director implement a policy requiring the Logistics Service perform recurring, at least annually, quality reviews of Research Service automated equipment data to identify and correct incomplete, inaccurate, and unreliable records, maintain copies of the reviews, and provide the completed reviews to the director.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2019
The OIG recommended the VA Eastern Colorado Health Care System Director implement a policy requiring the Logistics Service perform recurring quality reviews, at least annually, to ensure equipment transaction records are maintained, logically organized, and easily accessible for assigned research equipment, in accordance with policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The OIG recommended the VA Eastern Colorado Health Care System Director develop a local policy requiring the Logistics Service to perform recurring reviews of inventory dates for all Research Service accountable equipment and sensitive items, to ensure all equipment has been inventoried on an annual basis, which is from the month of completion to the next 12-month period, as required by VA Handbook 7002.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director implement a procedure to ensure compliance with the VA Handbook 6500.1 requirement to attach VA Form 0751, Information Technology Equipment Sanitization Certificate, to VA Form 2237, Request, Turn-In, and Receipt for Property or Services, prior to disposal of sensitive information technology equipment.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director take steps necessary to ensure required Report of Survey actions listed in VA Handbook 7002 are completed for the missing items reported lost by the Research Service on the eight Reports of Survey initiated in calendar year 2015.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director require the accountable officer to follow policy, establish, and maintain a Report of Survey register by fiscal year, to track, monitor, and ensure required actions are completed timely.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure there are an adequate number of officials who have the required training to complete Report of Survey actions so Reports of Survey can be fully processed, timely.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director implement a mechanism to ensure all Research Service Custodial Officers complete their required annual Custodial Officer’s training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure Delegation of Authority letters for all current Research Service Custodial Officers are completed in accordance with VA Handbook 7002.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure all materials and specimens are stored in a freezer with a remote temperature monitoring system.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure exterior doors on Research Service buildings are repaired so they consistently lock upon closure.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director ensure all exterior doors to Research Service buildings are secured by self-closing doors with automatic locking upon closure with access by keycard or a system that is equal to or exceeds the security of a keycard system.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The OIG recommended the VA Eastern Colorado Health Care System Director establish procedures to timely decommission vacant laboratories, and collect, store or dispose of unused chemicals and personally identifiable information in accordance with applicable policies.
Comprehensive Healthcare Inspection Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York
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17-05407-141

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2018
The Chief of Staff ensures the Executive Committee of the Medical Staff uses the results of Ongoing Professional Practice Evaluations in the determination of whether to recommend continuation of licensed independent practitioners’ privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2018
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from the Chief, Business Office Revenue-Utilization Review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
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 the Patient Safety Manager’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2019
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: 12/12/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Associate Director ensures medical biohazardous waste storage rooms are secured and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Facility Director ensures that controlled substances inspectors perform controlled substances order verification as required and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Facility Director ensures controlled substances inspectors complete monthly pharmacy prescription pad inventories and monitors inspectors’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Chief of Staff ensures providers communicate mammogram results to patients and monitors providers’ compliance.
Healthcare Inspection—Inadequate Intensivist Coverage and Surgery Service Concerns, Gulf Coast Veterans Healthcare System, Biloxi, Mississippi
|
17-03399-150

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
We recommended that the System Director continue to follow through on incomplete actions as discussed in Issues 1 and 2 of this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
We recommended that the Veterans Integrated Service Network Director provide oversight of intensive care unit and Surgery Service-related operations until corrective actions are completed and conditions have been resolved.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that the System Director take action as appropriate related to Physicians A and B and their improper electronic health record documentation as discussed in this report.
Comprehensive Healthcare Inspection Program Review of the Martinsburg VA Medical Center, West Virginia
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17-05409-140

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2019
The Acting Chief of Staff ensures the development and utilization of privilege-specific criteria for Focused Professional Practice Evaluations and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2019
The Acting Chief of Staff ensures the development and utilization of service-specific criteria for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2019
The Associate Director ensures all required environment of care team members are assigned to and consistently participate on environment of care rounds and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2018
The Facility Director ensures that Controlled Substance Inspectors complete controlled substance order verifications and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2019
The Acting Chief of Staff ensures mammogram results are electronically linked to the radiology order and monitors compliance.
Review of Alleged Unsecured Patient Database at the VA Long Beach Healthcare System
|
15-04745-48

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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 Under Secretary for Health ensure the Spinal Cord Injury program complies with VA’s Privacy Program and information security requirements for all veteran sensitive data collected.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2018
The OIG recommended the Executive Director for the National Spinal Cord Injury Program Office discontinue the use of unauthorized versions of Microsoft Access for the storage of Spinal Cord Injury program data and implement an approved system to support its data storage and analysis needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/5/2018
The OIG recommended the Acting Assistant Secretary for Information Technology ensure that VA’s Field Security Services and Privacy Service implement improved procedures to identify unauthorized uses of Sensitive Personal Information and train the facility information security officers and privacy officer to ensure that appropriate corrective actions are taken.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 8/30/2018
The OIG recommended VA’s Field Security Services and Privacy Service conduct a formal review of Spinal Cord Injury projects to identify acceptable disclosures of veteran Sensitive Personal Information and ensure that appropriate safeguards are implemented to protect the confidentiality of veteran data.
Review of Timeliness of the Appeals Process
|
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.
Review of Resident and Part-Time Physician Time and Attendance at Oklahoma City VA Health Care System
|
17-00253-93

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director ensure local policies and procedures are established for resident educational activity record keeping, monitoring resident participation in assigned educational activities, and reconciling VA educational activity with invoices submitted by the University of Oklahoma College of Medicine.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director ensure all staff involved in educational activity record keeping receive initial and annual refresher training on how to maintain the records.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director establish procedures to ensure agreed-upon salary and benefits rates for residents are properly approved by the Office of Academic Affiliations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The OIG recommended the Oklahoma City VA Health Care System Director require the medical school to submit adequate documentation tosupport its benefits rate for Social Security and Medicare costs for residents who are exempt from those taxes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director ensure the Designated Education Officer certifies final invoices for payment after all discrepancies identified in the reconciliation process are resolved.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director ensure the Designated Education Officer approves and maintains copies of the approved agreements for all off-site educational activities each academic year.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
The OIG recommended the Oklahoma City VA Health Care System Director review all academic year 2015–2016 invoices and initiateactions to recover overpayments from the medical school for residents who worked at non-VA facilities without prior written approval of the VA site directors and Designated Education Officer.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director appoint a team to conduct periodic audits of the disbursement agreement, including educational activity record keeping at the service and section level, reconciliation procedures, and the accuracy of the invoices submitted by the medical school.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The OIG recommended the Oklahoma City VA Health Care System Director ensure service chiefs conduct required reviews of part-time physicians to ensure they are working as scheduled.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
The OIG recommended the Oklahoma City VA Health Care System Director require service chiefs and supervisors ensure part-time physicians on adjustable work schedules enter their work hours in the electronic subsidiary record on a daily basis.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2019
The OIG recommended the Oklahoma City VA Health Care System Director ensure that all overdue reconciliations of part-time physicians’ adjustable work hour agreements identified in the report are performed and actions are taken to address over- and underpayments.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The OIG recommended the Oklahoma City VA Health Care System Director establish procedures to verify that all reconciliations of part-time physicians’ adjustable work hour agreements are completed timely.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
The OIG recommended the Oklahoma City VA Health Care System Director ensure service chiefs conduct quarterly reviews of all part-time physicians on adjustable work schedules.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 7,407,000.00
Comprehensive Healthcare Inspection Program Review of the Fayetteville VA Medical Center, North Carolina
|
17-01856-135

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2018
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: 8/2/2018
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Facility Interim Director ensures that required representatives of the interdisciplinary group consistently attend meetings and review utilization management data, and monitors the group’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The Facility Interim Director ensures that the Patient Safety Manager submits an annual patient safety report to facility leaders at the completion of each fiscal year and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating patients on anticoagulant medications and monitors clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Chief of Staff ensures providers consistently document patient or surrogate informed consent and identify the receiving provider for patients transferred out of the facility and monitors the providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Chief of Staff ensures that clinicians consistently communicate pertinent patient information to the receiving facility when patients are transferred out of the facility and monitors the clinicians’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2018
The Associate Director ensures that 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 compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2019
The Chief of Staff ensures that acceptable providers perform suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2020
The Chief of Staff ensures that acceptable providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of the referral and monitors providers’ compliance.
Comprehensive Healthcare Inspection Program Review of the VA Illiana Health Care System, Danville, Illinois
|
17-05424-142

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2018
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 the Service Chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures all required members attend the Utilization Management Committee meetings on an ongoing basis and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Associate Director ensures that temperature monitoring occurs in all dry food storage areas and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Chief of Staff ensures ordering providers communicate mammogram results to patients and monitors providers’ compliance.
Comprehensive Healthcare Inspection Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee
|
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
|
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
|
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.
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