Date Issued
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Report Number
14-03368-97
All Reports
Date Issued
|
Report Number
14-02890-409
Date Issued
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Report Number
14-02890-126
Date Issued
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Report Number
14-02890-96
Date Issued
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Report Number
14-02890-116
Date Issued
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Report Number
14-02890-129
Date Issued
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Report Number
16-02094-219
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/18/2017
We recommended that the Facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.
Date Issued
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Report Number
15-01325-205
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director ensure that program staff coordinate mental health appointments, including verifying the necessity, between facility providers and assigned community nursing home physicians prior to scheduling.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that the Facility Director ensure clinical staff report suspected elder abuse within the required timeframe and document the reporting in the patient’s electronic health record.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/29/2017
We recommended that the Facility Director ensure Non-VA Care Coordination staff timely deliver authorizations for consulted services to contracted community nursing home staff and that facility scheduling staff recognize when patients reside in a community nursing home and coordinate appointments with program or contracted community nursing home staff to ensure timely response to consults.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director require program registered nurses and social workers consistently conduct monthly or quarterly follow-up visits and ensure timely resolution of patient care needs identified in these visits.
Date Issued
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Report Number
16-00571-207
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data twice a year and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers ensure peer reviewers consistently document their use of at least one of the important aspects of care and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
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. 4
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that the Patient Safety Manager enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/24/2017
We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
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 and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
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. 11
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that Residential Recovery Center employees perform and document contraband inspections and rounds of public spaces and that managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.
Date Issued
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Report Number
16-00354-201
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/14/2017
We recommended the System Director ensure Mental Health schedulers consistently make direct contact with patients prior to scheduling appointments and that compliance is monitored for a minimum of three months.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/29/2017
We recommended the System Director ensure training and competencies are documented, complete, and up to date for all staff responsible for scheduling Mental Health appointments.
Date Issued
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Report Number
16-00564-170
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
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: 9/21/2017
We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that Environment of Care Council meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure fire extinguisher locations are clearly identified.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure information technology network room visitor logs contain all the required elements and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that employees store expired medications separately from medications available for administration and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure standard operating procedures for the bronchoscope are consistent with the manufacturer's instructions for use.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
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. 13
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 5/15/2018
We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that providers perform history and physical examinations within 30 calendar days prior to the moderate sedation procedure and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 5/15/2018
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. 17
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the facility correct the deficiencies identified for the Mental Health Residential Rehabilitation Treatment Program and that documentation reflects correction actions taken.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure the review of the hazardous materials inventory at the Marshalltown CBOC occurs twice within a 12-month period.
Date Issued
|
Report Number
16-00565-154
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that facility managers implement the use of a visitors log during non-business hours and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the facility perform quality control testing on all endoscopes and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the facility review quality assurance data for the anticoagulation management program quarterly as defined by local policy and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/28/2017
We recommended that for patients transferred out of the facility, transferring providers consistently include documentation of patient or surrogate informed consent, VA Form 10-2649B, in transfer documentation and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that providers consistently complete VA Form 10-2649A for patients transferred out of the facility and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
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 and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/26/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior 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
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Program employees at Lake Baldwin conduct and document daily bed checks and that program managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that facility managers ensure all Mental Health Residential Rehabilitation Treatment Program emergency exit door alarms are functional and turned on at all times and that program managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/20/2018
We recommended that facility managers ensure all closed circuit television monitoring cameras at the Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Programs have recording capability and that program managers monitor compliance.
Date Issued
|
Report Number
16-03920-197
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure a medical physicist inspects computed tomography scanners after completion of repairs or modifications that affect the dose or image quality prior to returning the scanners to clinical service.
Date Issued
|
Report Number
15-00223-196
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that peer reviewers identify and evaluate surgical and non-surgical clinical events [redacted pursuant to 38 U.S.C. § 5705].
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director maintain full compliance with the Veterans Health Administration’s peer review directive when service-level committees conduct initial peer reviews and consider ensuring secondary review of all such cases [redacted pursuant to 38 U.S.C. § 5705].
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that the Peer Review Committee provides final Level of Care assignments in writing for all cases brought before it.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that service chiefs select peer reviewers to conduct initial peer reviews and that protected peer review processes provide means for peer reviewers to withdraw when uncomfortable about conducting reviews.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that initial peer reviewers possess the qualifications required of peers relative to the episodes of care under review.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director review all cases [redacted pursuant to 38 U.S.C. § 5705]. and repeat the initial peer review process for those cases not conducted in compliance with the Veterans Health Administration’s peer review directive.
Date Issued
|
Report Number
16-00376-133
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 4/6/2017
We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
No. 2
to Information and Technology (OIT)
Closure Date: 8/15/2017
We recommended the Assistant Secretary for Information and Technology implement review processes to monitor the performance of the facility chief information officers, information security officers, and technical staff on the identification of external system interconnections and the required change control processes.
No. 3
to Information and Technology (OIT)
Closure Date: 4/6/2017
We recommended the Assistant Secretary for Information and Technology, in conjunction with the Wichita VA Regional Office Director, ensure that VA's system interconnection with the Kansas Commission on Veterans Affairs Office is brought into compliance with VA Information Security requirements and is authorized by an Interconnection Security Agreement and Facility Compliance Report.
No. 4
to Information and Technology (OIT)
Closure Date: 8/15/2017
We recommended the Assistant Secretary for Information and Technology conduct an annual review of all Veterans Service Organization systems connected to VA¿s network and ensure that appropriate Interconnection Service Agreements are in place and enforced for those connections.
No. 5
to Information and Technology (OIT)
Closure Date: 4/6/2017
We recommended the Assistant Secretary for Information Technology implement improved change management controls to prevent the establishment of Virtual Private Network concurrent network connections that are not in accordance with VA policy.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 7/27/2017
We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
Date Issued
|
Report Number
17-00976-176
Date Issued
|
Report Number
17-01000-177
Date Issued
|
Report Number
16-03743-193
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/29/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/9/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.
Date Issued
|
Report Number
15-04976-191
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
We recommended that the System Director ensure that nursing staff comply with pressure ulcer documentation requirements and physician providers routinely document participation in the interdisciplinary plan for patients with pressure ulcers.