All Reports

Healthcare Inspection—Patient Deaths, Opioid Prescribing Practices, and Consult Management, VA Greater Los Angeles Healthcare System,
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15-01669-246

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Delays in the Evaluation and Care of a Patient with Lung Cancer, VA Southern Nevada Health Care System, Las Vegas, NV
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15-01301-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Nutrition and Food Service Environment of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois
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16-03302-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities
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16-03808-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Quality of Care Concerns of a Surgical Patient, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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15-04516-229

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Alleged Pathology and Laboratory Medicine Service Quality of Care Issues, Wilmington, VA Medical Center, Wilmington, Delaware
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14-04524-224

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of VA’s Compliance With the Improper Payments Elimination and Recovery Act for FY 2016
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16-04416-231

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No. 1
Not Implemented Recommendation Image, X character'
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
Not Implemented Recommendation Image, X character'
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
Not Implemented Recommendation Image, X character'
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
Not Implemented Recommendation Image, X character'
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
Closed and Implemented Recommendation Image, Checkmark
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
Not Implemented Recommendation Image, X character'
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
Not Implemented Recommendation Image, X character'
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Patient Care Concerns at the Community Living Center, Hampton VA Medical Center, Hampton, Virginia
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15-02009-227

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Summary Report – Evaluation of Compounded Sterile Product Practices in Veterans Health Administration Facilities
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16-03807-223

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Consult Management Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California
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15-04681-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that providers assign the proper inpatient/outpatient setting and urgency of consults in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff take action within 7 days of a consult request or sooner if clinically indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff timely close or discontinue consults.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2017
We recommended that the Facility Director ensure that staff conduct a review on the quality and timeliness of the cardiology care for Patient 1 as discussed in the report, and take action if appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff monitor and address the care needs of patients on the Homemaker/Home Health Aide services electronic wait list.
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