All Reports

Inspection of the VA Regional Office Atlanta, Georgia
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16-05468-282

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases are appropriately distributed to the most qualifiedpersonnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to monitor the effectiveness of training on higher-level SpecialMonthly Compensation and Ancillary Benefits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases receive an accurate, signed second-level review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Southeast District Director implement a plan toensure the Atlanta VA Regional Office Director provides oversight andprioritization of proposed rating reductions claims for completion at theend of the due process period.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended that the Atlanta VA Regional Office Director ensureclaims assistants receive all systems compliance related training relevantto claims establishment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended that the Atlanta VA Regional Office Directorimplement a plan to modify the quality review checklist on claimsestablishment to include claim label and claimed issue classification indicators for all claims.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure claims processing staff properly establish and maintainend product 500s for control of special controlled correspondence.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure staff adhere to Veterans Benefits Administration policyand acknowledge special controlled correspondence with a timely interimor full response.
Inspection of the VA Regional Office, New Orleans, Louisiana
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16-04626-280

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Directorimplement a plan to assess the effectiveness of secondary reviews forSpecial Monthly Compensation and ancillary benefits claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2018
We recommended the Continental District Director implement a plan toensure oversight and prioritization of proposed rating reduction cases forcompletion at the end of the due process time period at the New OrleansVA Regional Office.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2017
We recommended the New Orleans VA Regional Office Director ensureclaims assistants receive all mandatory annual training on claimsestablishment procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Directorimplement a plan to strengthen the review process to assess all elementsrequired when establishing claims in the electronic record.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Directorprovide training to Legal Administrative Specialists responsible forprocessing controlled correspondence and monitor the effectiveness ofthe training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Director ensureLegal Administrative Specialists adhere to Veterans Benefits Administration policy when processing special controlled correspondence.
Review of Alleged Delay of Care and Scheduling Issues at the VAMC in West Palm Beach, FL
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15-02583-256

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure recruitment efforts are progressing to fulfill cardiology clinic vacancies and that there are sufficient cardiologists for the needs of the Medical Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure all scheduling staff are trained on the requirement to reschedule appointments canceled by the clinic within 14 days of the original appointment date.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure schedulers are using the clinically indicated or preferred appointment dates when scheduling appointments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure supervisors perform the required number of scheduling audits for each scheduler as required by VAMC policy.
Audit of VHA's Consolidated Patient Account Center Controls To Prevent Improper Billings for Service-Connected Conditions
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16-00589-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Centers review a statistical sample of bills issued during fiscal years 2015 and 2016 for the treatment of service-connected veterans to identify erroneously billed amounts that require refunds, and use these results to address internal control deficiencies and assess what additional efforts can be taken to identify and refund erroneously billed amounts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to provide billing staff read-only access to the Veterans Benefits Management System to identify potential service-connected bills that require review by Revenue Utilization Review nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management establish oversight procedures to review statistical samples of prescriptions prior to generating bills to veterans and to address any identified systemic or facility-specific billing problems.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise quality assurance reviews to include reviews of pharmacy bills and evaluate whether Revenue Utilization Review nurses correctly validate or make service-connection determinations for veterans’ medical treatment based upon staffing and workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise policy and procedure to require Consolidated Patient Account Center staff to adequately provide and document training for VA medical facility staff regarding specific service-connection determination errors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to track and monitor incorrect medical provider service-connection determinations and coordinate training to ensure identified issues are appropriately addressed.
Review of VA’s Readiness To Implement the Digital Accountability and Transparency Act
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16-02454-250

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Establish milestones to monitor VA’s system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Obtain procurement and grants management system capability that is integrated with the financial system as part of VA’s transition to a shared service provider to the extent feasible.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Improve communication with, and accountability of, administrations and offices and their points of contact who are responsible for providing data and documentation. Accountability should include timely, complete, and accurate submissions to the Project Management Office.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue working with the points of contact to ensure program information for all funds is submitted as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Identify internal controls and develop standard operating procedures for the processes used to obtain, extract, classify, and summarize data from VA’s financial and management systems to comply with the DATA Act schema.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: In conjunction with VA’s component organizations, perform an assessment of how business, accounting, and payment processes interact with one another for the purpose of establishing relevant policies and procedures to improve VA’s data quality. This assessment should include VA’s subsidiary systems and their interface status with the general ledger system, that is Financial Management System.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Ensure complete reconciliations are performed between the subsidiary and general ledger systems. Differences should be researched and resolved to improve data quality.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue to work on minimizing the use of the Management Information Exchange to record journal vouchers that are not linked to obligation and expenditure data by object class or program activity, or devise a mechanism to track such information when recording Management Information Exchange journal vouchers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Perform reconciliations between VA’s procurement systems (Electronic Contract Management System and Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system) and Financial Management System to ensure consistency, accuracy, and completeness of financial and procurement data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Provide resources for data storage capabilities to improve auditability of data. Specifically, VA should establish a data storage mechanism such as a shared drive to store data received from points of contact or developed internally by the Project Management Office. Such information should be secured, readily available for analysis and requests, validated, and auditable.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Ensure proper segregation of duties between staff responsible for processing data for submission to the data broker and staff responsible for validating the accuracy and completeness of data prior to submission to the data broker.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Provide necessary resources to the VA DATA Act Project Management Office to ensure that the office can coordinate the data inventory, mapping, and validation for the required DATA Act Schema data elements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Require administration points of contact to respond timely to Project Management Office data requests to ensure that the data elements can be inventoried, mapped, and validated and that gap analyses are performed thoroughly.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Use the data inventory and mapping to support VA’s move to a shared service provider and ensure full compliance with the DATA Act.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Establish procedures for data edits and validations to ensure that DATA Act submissionsare accurate and complete. At a minimum, management should selectively test internalcontrols related to the preparation of data submissions.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Assess the impact of the internal control weaknesses, as reported by VA’s financialstatement audit, on DATA Act data, and develop alternative processes to address data quality issues.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue to maintain communication with the Office of Management and Budget andTreasury regarding VA’s data reporting limitations and progress, and document suchcommunication.
Clinical Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York
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16-00558-311

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that for patients transferred out of the facility, providers consistently include date of transfer and documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that the facility trend the use of reversal agents in moderate sedation cases, that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events, and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2018
We recommended that providers include the history of previous adverse experiences with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that clinical managers ensure employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2017
We recommended that the facility establish a Community Nursing Home Oversight Committee.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility managers ensure clinical visits occur within the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that facility managers ensure all employees receive additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2017
We recommended that the Facility Director immediately remove unauthorized employees’ access to the medication room, evaluate access for all medication rooms within the facility, and take corrective action to meet Veterans Health Administration requirements.
Clinical Assessment Program Review of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
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16-00566-314

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the Quality, Safety, and Value Committee be consistently chaired or co-chaired by the Facility Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2019
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that facility managers ensure carpets and tile floors in patient care areas are clean and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug-to-drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior and a Disruptive Behavior Committee/Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that clinicians enter orders for mammograms in the Computerized Patient Record System and that clinical managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians screen patients for tetanus vaccinations at clinic visits and that clinical managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2018
We recommended that clinicians document all required vaccine administration elements and that clinical managers monitor compliance.
Healthcare Inspection Veterans Choice Program Dermatology Delays, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
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16-02551-306

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Federal Health Care Center Director ensure that fee department staff take timely action when providers order non-VA care and Choice dermatology consults.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Federal Health Care Center Director ensure that fee department staff take timely action to complete, cancel, or discontinue non-VA care and Choice dermatology consults, as appropriate.
Inspection of the VA Regional Office Indianapolis, Indiana
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16-04918-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended the Indianapolis VA Regional Office Director ensure and implement local training that complies with Veterans Benefits Administration policy and implement plans to ensure the effectiveness of that training for evaluation of higher-level Special Monthly Compensation claim and ancillary benefits.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended the Midwest District Director implement a plan to ensure the Indianapolis VA Regional Office Director provides oversight and prioritization of proposed rating reduction cases for completion at the end of the due process time period.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended that the Indianapolis VA Regional Office Director provide training to Claims Assistant on how to assign the correct medical classification to claimed disabilities and monitor the effectiveness of that training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended that the Indianapolis VA Regional Office Director implement a plan to modify the quality review checklist on claims establishment to include “claimed issue with classification” and “special issue” indicators for all claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2017
We recommended the Indianapolis VA Regional Office Director implement a plan to comply with Veteran Benefits Administration policy for managing and processing special controlled correspondence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended the Indianapolis VA Regional Office Director provide training to the Congressional Liaison responsible for processing special controlled correspondence.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended the Indianapolis VA Regional Office Director develop and implement a plan to assess the effectiveness of the special controlled correspondence checklist.
Inspection of the VA Regional Office Seattle, Washington
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16-04764-266

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/12/2018
We recommended the Seattle VA Regional Office Director implement a plan to ensure traumatic brain injury claims are assigned to qualified Rating Veterans Service Representatives for processing.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/19/2017
We recommended the Seattle VA Regional Office Director implement a plan to provide refresher training on traumatic brain injury and monitor the effectiveness of that training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/12/2018
We recommended the Seattle VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for traumatic brain injury and special monthly compensation rating decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director develop and implement a plan to provide refresher training to Rating Veterans Service Representatives regarding proper procedure for applying effective dates.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the end of the due process time period.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director implement a plan to conduct comprehensive training for claims establishment staff that emphasizes the importance of ensuring all elements are considered when establishing claims, and assess the effectiveness of that training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director implement a plan to ensure data input at the time of claims establishment are reviewed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director monitor the effectiveness of the training regarding how to properly upload emails into electronic claims folders, and conduct refresher training as necessary.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director implement a training plan to ensure all status updates on inquiries are made part of the electronic records, and monitor the effectiveness of that training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2017
We recommended the Seattle VA Regional Office Director implement a plan to provide oversight and quality review of all types of special controlled correspondence.
Healthcare Inspection – Alleged Inadequate Mental Health Care, Iowa City VA Health Care System, Iowa City, Iowa
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16-04535-329

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the Acting Under Secretary for Health ensure that facility staff conduct thorough post suicide reviews to include all information that provides valuable context and details related to the event.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2018
We recommended that the System Director ensure that the system No-Show policy and practice for mental health patients is in alignment with the expectations of the Office of Mental Health Operations and that system leaders monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2018
We recommended that the System Director ensure that clinicians update outpatient mental health treatment plans according to applicable requirements and guidance and that system leaders monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2018
We recommended that the System Director ensure that the Mental Health Treatment Coordinator program complies with VHA requirements and guidance, and that system leaders monitor compliance.
Administrative Investigation - Improper Approval and Use of Leave, VA Medical Center, Chillicothe, Ohio
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15-04374-313

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2018
We recommend the Network Director confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Ms. Hepker.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2018
We recommend the Network Director confer with the Offices of Human Resources and General Counsel to review Dr. Johnston’s improper use of sick leave, and consider whether VA should seek recoupment or waive the improper pay and allowances in accordance with VA Financial Policies and Procedures § 010508.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Network Director confer with Ms. Hepker to review and revise the local VAMC leave policy, Policy Memorandum No. 05-01 (Leave Administration), to ensure it is consistent with VA’s policy, VA Handbook 5011, limiting the approval of LWOP to employee’s who are reasonably expected to return to duty.
Clinical Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
|
16-00576-310

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure air conditioner and steam/heat ventilation grills in the Emergency Department are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that facility managers ensure refrigerators in patient nourishment kitchens do not contain unlabeled food items and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that the facility implement a policy for cleaning, disinfecting, and sterilizing reusable medical equipment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure standard operating procedures for the colonoscope, esophagogastroduodenoscope, and duodenoscope are consistent with the manufacturers' instructions for use.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that hemodialysis unit employees secure chemicals when not in use and that the hemodialysis unit manager monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
We recommended that providers consistently complete VA form 10-2649A or use a properly templated inter-facility transfer note template for patients transferred out of the facility and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in VA Form 10-2649A, Inter-Facility Transfer Form, and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that sending nurses document transfer assessments/notes for patients transferred out of the facility and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
We recommended that facility managers ensure that for emergent transfers, provider transfer notes include a statement of patient stability for transfer and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that employees perform quality control on glucometers in accordance with the facility's policy/standard operating procedure and the manufacturer's recommendations and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that providers include history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that clinical employees discharge outpatients from the recovery area with orders given by a qualified provider or according to criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that the facility integrate the community nursing home program into its quality improvement program.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure Disruptive Behavior Committee discussion of patients' disruptive or violent behavior and entry of a progress note into the patients' electronic health records.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire, ensure training is documented in employee training records, and monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document every 2-hour rounds of all public spaces, daily bed checks, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that facility managers ensure the Substance Abuse Residential Rehabilitation Treatment Program unit's non-main entry door is alarmed at all times and that program managers monitor compliance.
Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC
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15-01119-315

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Mr. Hawkins.
Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care
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17-01846-316

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that the Acting Under Secretary for Health require that all participating VA purchased care providers receive and review the evidence-based guidelines outlined in the Opioid Safety Initiative.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that the Acting Under Secretary for Health implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history until a more permanent electronic record sharing solution can be implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that the Acting Under Secretary for Health require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording of the prescriptions in the patient’s VA electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2019
We recommended that the Acting Under Secretary for Health ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with Opioid Safety Initiative guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.
Inspection of the Veterans Service Center Cheyenne, Wyoming
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17-00962-262

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended that the Denver VA Regional Office Director ensure that the Cheyenne Veterans Service Center implement a plan to ensure that all claims processing staff receive training regarding the proper procedures for inputting dates of claim for system generated reminder notifications.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/9/2018
We recommended that the Denver VA Regional Office Director ensure that the Cheyenne Veterans Service Center implement a plan to perform monthly quality reviews of all employees who establish claims.
Clinical Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California
|
16-00579-293

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, corrective actions taken to address identified deficiencies, and tracking of corrective actions to closure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that the facility implement actions to address all high-risk areas and ensure Infection Control Committee minutes document those actions and the follow-up on actions implemented to address identified problems.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that the facility review quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure that clinicians consistently obtain all required laboratory tests prior to initiating anticoagulation warfarin treatment and that clinicians obtain initial prothrombin/international normalized ratio through laboratory testing.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility¿s capacity and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2018
We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags and ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2018
We recommended that clinicians provide education and counseling to patients with positive alcohol screens and who reported drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
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