Date Issued
|
Report Number
15-04365-328
All Reports
Date Issued
|
Report Number
16-01077-255
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that the Facility Director develop processes to ensure that the relevant providers complete timely patient evaluations for continued long-term opioid therapy for pain based on clinically significant changes or findings to a patient’s health status.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that reviews of the cases of the identified patients with clinically significant changes are completed and take action as appropriate.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers receive education on the concurrent prescribing of dual short acting opioids and tapering of opioids.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers review Veterans Health Administration recommendations regarding the use of opioid risk stratification tools, such as the Opioid Risk Tool, to identify high-risk patients for longterm opioid therapy for pain.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers order urine drug screening frequency based on risk assessment and complete urine drug screening at least annually.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers consistently use urine drug screening confirmatory testing.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director develop processes that minimize the potential for urine drug screening tampering.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers consistently complete the informed consent process prior to initiating long-term opioid therapy for pain as specified by Veterans Health Administration policy.
Date Issued
|
Report Number
16-00327-209
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/1/2017
We recommended the Acting Assistant Secretary for Human Resources and Administration assign responsibility to an office to assess hosting solution options for the Dashboard Tool.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/7/2018
We recommended the Acting Assistant Secretary for Human Resources and Administration evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool investment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Date Issued
|
Report Number
16-00581-239
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
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. 3
to Veterans Health Administration (VHA)
Closure Date: 1/8/2018
We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/8/2018
We recommended that facility managers ensure sharps containers stored for pick-up are secured and monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
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 that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/8/2018
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 and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
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.
Date Issued
|
Report Number
15-01043-247
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Battle Creek VA Medical Center Director ensure that Battle Creek VA Medical Center managers update the blood transfusion policy to align with AABB blood transfusion guidelines.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/22/2017
We recommended that the Battle Creek VA Medical Center Director ensure that providers follow Battle Creek VA Medical Center policy and report all transfusion adverse reactions to the Blood Usage Review Committee for review.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Battle Creek VA Medical Center Director ensure that the Transfusion Officer who is appointed to the Blood Usage Review Committee has no conflict of interest between committee and professional responsibilities.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that the Battle Creek VA Medical Center Director ensure that for level 2 and level 3 peer reviews, the Peer Review Committee provide recommendations to supervisors of non-punitive and non-disciplinary actions, that supervisors discuss and follow up with providers, and that Peer Review Committee minutes include documentation of actions and of supervisory follow-up as required by the Veterans Health Administration.
VA
Date Issued
|
Report Number
15-05235-200
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/2/2018
We recommended the San Juan VA Regional Office Director develop and implement a plan to review the 722 End Product 930s that staff removed from its inventory in August and September 2015.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2018
We recommended the San Juan VA Regional Office Director monitor the effectiveness of current plans to manage the End Product 930 workload.
Date Issued
|
Report Number
14-02890-95
Date Issued
|
Report Number
15-01669-246
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the System Director ensure staff conduct a review of canceled or discontinued cardiology consults to determine if patients suffered harm as a result of inappropriate consult closure and confer with the Office of Chief Counsel regarding disclosure as necessary.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/27/2017
We recommended that the System Director ensure system staff comply with current Veterans Health Administration policies regarding consult management.
Date Issued
|
Report Number
15-01301-242
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure that providers address and communicate test results to patients within the timeframe required by the Veterans Health Administration.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure that providers timely follow up on non-VA providers’ recommendations.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure the Non-VA Medical Care Coordination requirement for patients to be seen by system physicians first for services offered at the system before a Non-VA Medical Care Coordination request is authorized does not delay care.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure Non-VA Medical Care Coordination staff process requests according to the urgency noted by the requesting provider.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure Emergency Department providers follow Non-VA Medical Care Coordination consult request processes.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure that Non-VA Medical Care Coordination staff are knowledgeable of specific services that are authorized when Non-VA Medical Care Consults are approved.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director review existing practices for filling nonformulary/restricted medications to ensure that medications are ordered, reviewed, and processed timely.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director evaluate patient experiences regarding contracted companies’ processes for delivery of medications and take appropriate corrective actions if needed.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure the peer review process is conducted according to current Veterans Health Administration guidance.
Date Issued
|
Report Number
16-03302-252
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director complete an analysis of the basement and sub-basement structures to determine if adequate measures are in place to prevent water infiltration.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the Facility Director ensure that Nutrition and Food Service kitchen staffing is sufficient to perform all required duties including cleaning and sanitation.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the Facility Director complete an analysis of the feasibility of relocating the main kitchen to an area that limits the environmental conditions for pests.
Date Issued
|
Report Number
16-03808-215
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Suicide Prevention Coordinators provide at least five outreach activities per month and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete Suicide Prevention Safety Plans for all high-risk patients, include in the plans the contact numbers of family or friends for support, and give the patient and/or caregiver a copy of the plan, and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians, in consultation with Suicide Prevention Coordinators, identify inpatients as at high risk for suicide, they place Patient Record Flags in the patients' electronic health records and notify the Suicide Prevention Coordinator of each patient's admission, and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that a Suicide Prevention Coordinator or mental health provider evaluates inpatients identified as at high risk for suicide at least four times during the first 30 days after discharge, and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians identify outpatients as at high risk for suicide, they review the Patient Record Flags every 90 days and document the review and their justification for continuing or discontinuing the Patient Record Flags, and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete suicide risk management training within 90 days of hire and that facility managers monitor compliance.
Date Issued
|
Report Number
15-01653-226
Date Issued
|
Report Number
15-04516-229
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/26/2017
We recommended that the System Director ensure a peer review is conducted of this case to determine whether the risk of alcohol withdrawal was adequately assessed prior to the patient’s aortofemoral bypass graft surgery in 2015 and whether this patient’s inpatient medical management, including the complications presented by the patient’s prolonged alcohol withdrawal, was reasonable.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/17/2017
We recommended that the System Director modify the system’s restraint policy to include leadership notification of patients in medical restraints after a specified timeframe in restraints.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/17/2017
We recommended that the System Director ensure wound care documentation is consistent with system policy and monitor compliance.
Date Issued
|
Report Number
14-04524-224
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Facility Director ensure that Pathology and Laboratory Medicine Service staff establish and use acceptable processing procedures for pathology testing that will ensure established benchmark non-compliance rates for routine pathology test turnaround times, as established by VHA, are met and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Facility Director ensure that Pathology and Laboratory Medicine Service staff follow facility documentation requirements for non-VHA laboratory pathology reports and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Facility Director ensure that facility managers review the pathology tests performed at the unofficial non-VHA laboratory to determine whether quality assurance benchmarks were met and whether patient harm occurred, and if harm did occur, confer with the Office of Chief Counsel regarding the appropriateness of disclosures to patients and families.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Facility Director ensure that facility oversight services and committees for the Pathology and Laboratory Medicine Service review current performance data and follow Veterans Healthcare Administration and facility quality assurance policies and practices concerning reporting data, establishing action plans, and monitoring action plans, and that facility leadership monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Facility Director ensure that facility managers monitor and use current performance data, and complete ongoing professional performance evaluations and other internal reviews as required by Veterans Health Administration and facility policies.
Date Issued
|
Report Number
16-04416-231
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health develop a timeline to reduce improper payments under 10 percent for the VA Community Care and Purchased Long Term Services and Support Programs.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health implement steps to achieve reduction targets for the VA Community Care, Purchased Long Term Services and Support, Beneficiary Travel, Civilian Health and Medical Program of the Department of Veterans Affairs, State Home Per Diem Grants, and Supplies and Materials Programs.
No. 3
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Principal Executive Director, Office of Acquisition, Logistics, and Construction, implement additional training with respect to identifying unauthorized commitments and verifying pricing for personnel who evaluate Improper Payment Elimination and Recovery Act samples for the Supplies and Materials Program.
No. 4
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC),Office of Management (OM)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Acting Secretary for Management and Acting Chief Financial Officer, and the Principal Executive Director, Office of Acquisition, Logistics, and Construction, develop appropriate testing procedures for direct to patient and Federal Supply Schedule contract payments.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Veterans Benefits Administration implement steps to identify and report a reliable improper payment estimate for the Post-9/11 G.I. Bill Program.
No. 6
to Veterans Health Administration (VHA),Office of Management (OM)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Acting Assistant Secretary for Management and Acting Chief Financial Officer, provide the Improper Payment Elimination and Recovery Act team guidance to achieve the expected level of precision for the improper payment estimates for the VA Community Care and Purchased Long Term Services and Support Programs.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Benefits continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Benefits report any statutory barrier preventing complete resolution to drill pay improper payments in its Agency Financial Report.
Date Issued
|
Report Number
15-02009-227
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/11/2017
We recommended that the Facility Director ensure that Community Living Center staff have competency assessments and validations completed for care of residents with suprapubic catheters, including catheter insertion and irrigation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that the Facility Director strengthen processes to ensure that Community Living Center staff carry out physician orders for bladder irrigation and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that the Facility Director strengthen processes to ensure that Community Living Center staff conduct and document resident checks for well-being, skin assessments, and activities of daily living assistance as required and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/11/2017
We recommended that the Facility Director strengthen processes to ensure that procedures are followed for obtaining special care beds and mattresses.
Date Issued
|
Report Number
16-00932-203
Date Issued
|
Report Number
16-03807-223
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that for employees who prepare compounded sterile products, facilities include in their competency assessment requirements gloved fingertip sampling and the required number of gloved fingertip samplings for initial competency assessment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities include in the competency assessment checklists of employees who prepare compounded sterile products donning of personal protective equipment in the required order and performance of appropriate hand hygiene after personal protective equipment removal.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure competency assessments for employees who prepare compounded sterile products include gloved fingertip sampling, written tests, and visual observation or “hands-on” skill assessment of aseptic technique at the required risk level frequency.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure sterile chemotherapy-type gloves are available in areas where hazardous compounded sterile products are prepared.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure employees clean sterile compounding area floors daily and storage shelving monthly and document the cleaning.
Date Issued
|
Report Number
15-00408-204
Date Issued
|
Report Number
14-02890-169ccc