All Reports

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
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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.
Healthcare Inspection - Management of Mental Health Care Concerns, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
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16-00748-319

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the Facility Director ensure that Mental Health Residential Rehabilitation Treatment Program local policies are consistent with the Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Handbook and Mental Health Residential Treatment Program leaders and staff adhere to the policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the Facility Director ensure that the Mental Health Residential Rehabilitation Treatment Program managers monitor compliance as outlined by Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Handbook.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the Facility Director ensure that the Mental Health Residential Rehabilitation Treatment Program has adequate resources, including staff, as specified by the Mental Health Residential Rehabilitation Treatment Program Handbook to provide a safe therapeutic environment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the Facility Director ensure full implementation of the Acute Mental Health Inpatient Unit visitation policy and monitor for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the Facility Director implement assignments of Mental Health Treatment Coordinators to mental health patients and strategies to enhance communication and coordination across mental health clinical areas.
Clinical Assessment Program Review of the Montana VA Health Care System, Fort Harrison, Montana
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16-00573-309

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2017
We recommended that the facility replace missing and stained ceiling tiles in patient care areas and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2017
We recommended that facility managers ensure standard operating procedures for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with the manufacturers’ instructions for use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that Sterile Processing Service employees document positive quality control testing results for colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography in a manner that allows tracking of actions taken and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2017
We recommended that the facility provide patients with a direct telephone number for anticoagulation-related calls during normal business hours and define a process for anticoagulation calls outside normal business hours.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2017
We recommended that the facility designate a physician anticoagulation program champion.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that the facility note the absence of adverse events in Operative and Invasive Procedure Committee reports and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that clinical managers ensure clinical employees who perform or assist with moderate sedation procedures have current Talent Management System training for the provision of moderate sedation care, ensure the training is documented, and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2017
We recommended that the facility revise the policy on ensuring correct surgery and invasive procedures to include all elements of the timeout checklist required by Veterans Health Administration Directive 1039.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that facility managers ensure social workers conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that the facility revise the workplace violence prevention policy to include required membership for the Disruptive Behavior Committee.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters Patient Record Flags into the electronic health records.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2018
We recommended that the facility implement a process to ensure all surgical deaths are tracked and reviewed by appropriate clinical employees.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that acute care employees accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended that clinic employees document in patients’ electronic health records medication reconciliation that includes the newly prescribed fluoroquinolone, patient counseling/education that includes the fluoroquinolone, and evaluation of the patients’ level of understanding of the education.
Audit of VHA's Alleged Inappropriate Scheduling of Electromyography Consults at the Memphis VA Medical Center
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16-02468-281

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended the Director of the Memphis VA Medical Center ensure Neurology Clinic staff schedule veterans referred to the Electromyography Clinic and place veterans on the Veterans¿ Choice List in accordance with Veterans Choice Program guidance when appointments are scheduled 30 days beyond the clinically indicated date.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2018
We recommended the Director of the Memphis VA Medical Center ensure the VA Electromyography Clinic has sufficient staffing resources to comply with VHA’s scheduling policy to act on consults within seven days.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2018
We recommended the Director of the Memphis VA Medical Center ensure the Business Office has sufficient staffing resources to enable timely processing of Veterans Choice Program consults.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended the Director of the Memphis VA Medical Center ensure staff review the six Veterans Choice Program consults for Electromyography services that were not scheduled for care.
Clinical Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky
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16-00580-303

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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 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: 12/19/2017
We recommended that the Infection Control Committee document analysis of surveillance data related to follow-up activities for the hemodialysis unit and Sterile Processing Service areas.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers at the Cooper Division implement the use of a visitors log during non-business hours and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers at the Cooper Division ensure ceiling ventilation grills in patient care areas are clean and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that Sterile Processing Service managers ensure quality control testing is performed on endoscopes that exceed a 12-day hang time and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training and competencies for the types of reusable medical equipment they reprocess.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure wall and ceiling holes and damage are repaired.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended that facility managers ensure employees entering Sterile Processing Service areas wear the required personal protective equipment and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended that facility managers ensure current standard operating procedures for reusable medical equipment are located in the area where reprocessing occurs.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2018
We recommended that facility managers ensure the distance of items stored below a sprinkler deflector complies with Joint Commission standards and 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 all hemodialysis unit employees receive annual bloodborne pathogens training and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the facility revise the anticoagulation management policy to include required baseline laboratory tests.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended that the facility review quality assurance data for the anticoagulation management program biannually and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers include nutrient interactions and drug to drug interactions associated with anticoagulation therapy in competency assessments for employees actively involved in the anticoagulant program and monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinical employees discharge outpatients from the recovery area according to provider orders or criteria approved by moderate sedation clinical leaders 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 clinical managers ensure that clinical employees who perform or assist with moderate sedation have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required disciplines.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the facility ensure integration of 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: 12/19/2017
We recommended that facility managers ensure that 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: 3/27/2018
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal flag placement and monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2019
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, ensure the training is documented in employee training records, and monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program monthly self-inspections include assessment of privacy and that facility managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure locked mental health unit panic alarm testing includes VA Police response time and monitor compliance.
Healthcare Inspection – Quality of Care and Other Concerns Robert J. Dole VA Medical Center, Wichita, Kansas
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15-04641-304

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/19/2017
We recommended that the Facility Director implement applicable recommendations from previous event-related reviews and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/19/2017
We recommended that the Facility Director ensure that processes are strengthened for the Hospice and Palliative Care Program and that appropriate designated staff are assigned to the Palliative Care Consult Team to adhere to Veterans Health Administration and facility policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/1/2017
We recommended that the Facility Director assess the need to define the required timeframe for attending physicians to return to the facility if needed for patient emergencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/19/2017
We recommended that the Facility Director ensure compliance with facility policy for clinicians designated to perform emergency airway management.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/19/2017
We recommended that the Facility Director ensure compliance with Veterans Health Administration policies on Emergency Department coverage.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/19/2017
We recommended that the Facility Director ensure the continued practice of physician only coverage for the role of nocturnist.
Administrative Investigation - Conflicting Interests and Misuse of Government Equipment, Overton Brooks VA Medical Center, Shreveport, Louisiana
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14-03508-275

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2017
We recommend that the VAMC Director confer with the Offices of General Counsel, Human Resources, and Accountability Review to determine the appropriate administrative action to take, if any, against Dr. (name redacted).
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2017
We recommend that the VAMC Director confer with the Offices of General Counsel, Human Resources, and Accountability Review to determine the appropriate administrative action to take, if any, against Ms. (name redacted).
No. 3
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 8/22/2018
We recommend that until such time as Congress either repeals or modifies 38 USC § 3683, VA OGC Ethics Group should also focus on 38 USC § 3683 in their annual Ethics training for all VA employees.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 5/25/2018
We recommend that VA OGC either enforce the law as written, or initiate the waiver provision found in subsection (d) of the statute.
Clinical Assessment Program Review of the El Paso VA Health Care System, El Paso, Texas
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16-00578-291

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2018
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data quarterly and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
We recommended that the facility consistently take actions when data analyses indicated problems or opportunities for improvement and evaluate them for effectiveness in root cause analyses and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
We recommended that the facility revise the policy for anticoagulation management to include an anticoagulation quality assurance program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
We recommended that the facility develop and implement processes to address noncompliance with the treatment plan.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
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: 12/12/2017
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2018
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2017
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
Quality of Care Concerns at Two Veterans Integrated Service Network 23 Facilities and a Veterans Readjustment Counseling Center
|
15-00509-301

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2018
We recommended that the St. Cloud VA Health Care System Director incorporate processes to ensure assessment of patient preference, plans for further treatment, and an adequate process for termination or transfer to VHA mental health services when non-VA mental health services are discontinued.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2017
We recommended that the St. Cloud VA Health Care System Director identify patients whose non-VA Post-Traumatic Stress Disorder services were terminated as discussed in this report, determine if the patients were offered and received mental health treatment, and take action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2017
We recommended that the Minneapolis VA Health Care System Director ensure compliance with Veteran Health Administration scheduling policies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2017
We recommended that the Minneapolis VA Health Care System Director ensure compliance with Veteran Health Administration communication of test results policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Chief Officer, Readjustment Counseling identify St. Paul Vet Center patients whose non-VA Post-Traumatic Stress Disorder services were terminated as discussed in this report, determine if the patients were offered and received mental health services, and take action as appropriate.
Clinical Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan
|
16-00549-302

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2018
We recommended that facility clinical managers 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: 2/27/2018
We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that facility repair malfunctioning medication carts or remove them from service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2018
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
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: 6/12/2019
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2018
We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts prior to moderate sedation procedures and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
We recommended that clinical managers ensure that licensed independent practitioners who perform moderate sedation procedures complete required 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: 12/18/2018
We recommended that facility managers ensure all required disciplines attend Community Nursing Home Oversight Committee meetings.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2018
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2018
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: 2/27/2018
We recommended that facility managers ensure the Disruptive Behavior Committee [DBC] maintains meeting minutes and a record of attendance for key committee members and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
We recommended that facility managers ensure employees consistently use the disruptive behavior reporting and tracking system and monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility clinical managers ensure clinicians inform patients about the right to request to amend/appeal Patient Record Flag placement.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility clinical managers ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
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.
Clinical Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
|
16-00568-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Menominee community based outpatient clinic and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2018
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2018
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that a VA physician order or approve all therapies that are at VA expense.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2018
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 training is documented in employee training records.
Healthcare Inspection—Clinical Activities, Staffing, and Administrative Practices, Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma
|
16-02676-297

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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 System Director take action to fill key leadership positions with qualified permanent personnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure that established workgroups continue efforts to improve Strategic Analytics for Improvement and Learning-related metrics, and that progress be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the System Director ensure that the Quality, Safety and Value’s subordinate committee minutes comply with Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure professional practice evaluations include performance data to support provider privileges and are conducted as outlined in Veterans Health Administration and local policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure that Service-level privilege lists are relevant to the care provided in the Service.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2018
We recommended that the Veterans Integrated Service Network Director consider an inter-rater reliability system or second-level review to ensure the correct application of the severity assessment code criteria.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure the local peer review policy includes all Veterans Health Administration policy requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure adherence to all national peer review program requirements, including the use of suitable peers in Peer Review Committee processes, and monitor for compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2018
We recommended that the System Director continue efforts to enhance access to care for Specialty Care and Mental Health clinics and monitor outcomes for continued improvement.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
We recommended that the System Director continue efforts to enhance call center timeliness and monitor outcomes for continued improvement.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network Director charter a team to conduct a follow-up site visit to ensure the System Director’s corrective actions taken in response to previous non-VA care-related recommendations were effective.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure that Patient Aligned Care Team clinicians follow Veterans Health Administration requirements for patient notification and follow-up of abnormal lab results.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the System Director monitor consult completion timeliness and identify process improvements for those exceeding 30 days.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2019
We recommended that the System Director ensure that a Mental Health-related Strategic Analytics for Improvement and Learning workgroup identify priorities, and develop and implement improvement actions accordingly.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2018
We recommended that the System Director ensure continued efforts to improve lengths of stay for patients being discharged from the Emergency Department.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.
Healthcare Inspection – Alleged Staffing, Quality of Care, and Administrative Deficiencies, Amarillo VA Health Care System, Amarillo, Texas
|
14-03822-289

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
We recommended that the Facility Director continue efforts to recruit and hire for nursing staff vacancies, and ensure that until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
We recommended that the Facility Director ensure members consistently attend Pressure Ulcer Committee meetings and document efficacy data on specific treatments, information on new treatment modalities, and action items, to include documentation of follow-up taken regarding action items.
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