All Reports

Review of Alleged Improper Non-VA Community Care Consult Practices at Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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14-02890-352

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended the Director, Ralph H. Johnson VAMC, initiate an additional clinical review regarding the patient identified in this report, and take action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended the Director, Ralph H. Johnson VAMC, ensure that consults that were not acted on within 7 days can be tracked and managed in accordance with national policy.
Healthcare Inspection – Review of Antimicrobial Stewardship Programs in VHA Facilities
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15-04247-111

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2017
We recommended that the Under Secretary for Health implement procedures to ensure that facilities comply with Veterans Health Administration Directive 1031 requirements, including the completion of annual evaluations, designation of provider and pharmacy champions, staff education, and the provision of adequate dedicated staffing and resources.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended that the Under Secretary for Health require that Veterans Health Administration facilities track and generate clinical outcome reports on antibiotic use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that the Under Secretary for Health consider implementing standardized tools and definitions for antimicrobial stewardship data and a uniform reporting system to permit analysis of comparable information over time.
Review of Alleged Misuse of VA Funds at the VA Pittsburgh Healthcare System
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15-02278-415

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2017
We recommended the Veterans Integrated Service Network 4 Director ensure the VA Pittsburgh Healthcare System conduct annual reviews to ensure its resident meal plans are appropriate and supported by adequate documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2017
We recommended the Veterans Integrated Service Network 4 Director ensure the VA Pittsburgh Healthcare System evaluate purchasing meals internally from the Veterans Canteen Service as an alternative to commercial sources.
Healthcare Inspection – Review of Complaints Regarding Mental Health Services Clinical and Administrative Processes, VA St. Louis Health Care System, St. Louis, Missouri
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14-03434-102

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting System Director ensure that Mental Health Service reviews daily psychiatric patient care activity and determine if productivity is consistent with work relative value unit-based productivity and meets reasonable expectations for number of patients treated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting System Director ensure that staff psychiatrists’ scheduling grids are consistent with expected patient care activity.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2017
We recommended that the Acting System Director ensure that processes be strengthened to review and rectify psychiatry staff’s Current Procedural Terminology coding errors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2017
We recommended that the Acting System Director ensure that processes be strengthened for timely response to mental health clinic group treatment patient referrals.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2017
We recommended that the Acting System Director ensure that mental health staff adequately assess and document treatment needs and follow-up arrangements for unscheduled (walk-in) patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting System Director ensure that facsimile machine numbers provided to referral sources are functional and appropriately located for timely response.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting System Director strengthen the Compensation and Pension evaluation documentation processes to enhance accuracy of information.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2017
We recommended that the Acting System Director ensure that processes be strengthened to include patients in treatment planning when they are transferred to another clinic.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2017
We recommended that the Acting System Director ensure that peer reviews are inclusive of all relevant clinicians and timely and that managers take appropriate follow-up actions, if indicated.
Review of Alleged Wasted Funds at Consolidated Patient Account Centers for Windows Enterprise Licenses
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16-00790-417

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/9/2020
We recommended the Assistant Secretary for Information and Technology implement a policy to ensure cost-effective utilization of information technology equipment, installed software, and services and ensure coordination of acquisitions with affected VA organizations. This will help ensure VA’s operating framework and organizational needs are considered prior to acquisitions.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 7,200,000.00
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