All Reports

Clinical Assessment Program Review of the Boise VA Medical Center, Boise, Idaho
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16-00557-134

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2017
We recommended that Environment of Care Committee meeting minutes consistently include discussion and analysis of environment of care rounds deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the facility revise the Ensuring Correct Surgery and Invasive Procedures policy to include all elements of the timeout checklist required by the Veterans Health Administration.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2017
We recommended that facility managers ensure the Community Nursing Home Oversight Committee meets at least quarterly and includes representation by all required disciplines.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2017
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews including the analysis of the latest state survey and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2017
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.
Combined Assessment Program Summary Report – Evaluation of Inpatient Flow in Veterans Health Administration Facilities
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16-03805-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities revise discharge policies to include encouraging physicians to schedule discharges early in the day.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities develop or revise policies addressing overflow patients in temporary bed locations and include priority placement for inpatient beds given to patients in temporary bed locations, upholding standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when resident physicians complete discharge notes or instructions, supervising physicians co-sign the residents’ notes.
Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 6
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16-02618-424

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended the Under Secretary for Health establish a method to monitor and ensure Veterans Integrated Service Network compliance with scheduling requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended the Director of Veterans Integrated Service Network 6 ensure that staff at all VA medical facilities use the referring provider’s clinically indicated date, when available, or documented veteran’s preferred appointment date, when scheduling new patient appointments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended the Director of Veterans Integrated Service Network 6 ensure VA medical facilities conduct required scheduler audits and take corrective actions as needed based on audit results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2018
We recommended the Under Secretary for Health implement monitoring controls to ensure the third-party administrators return authorizations after 2 business days for urgent care and 5 business days for routine care if an appointment had not been scheduled.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended the Director of Veterans Integrated Service Network 6 ensure Non-VACare Coordination staffing is sufficient to timely administer the requirements of the Choice Program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2018
We recommended the Under Secretary for Health implement controls to ensure the third party administrators create an appointment for the veteran within 5 business days of receiving an authorization.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2018
We recommended the Under Secretary for Health to ensure all data required to manage the third party administrator contracts provided by the VA and the third party administrators is complete, accurate, and timely.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
We recommended the Director of Veterans Integrated Service Network 6 ensure services monitor and timely address consults pending greater than 7 days.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
We recommended the Director of Veterans Integrated Service Network 6 identify and implement best practices to timely schedule appointments for consults upon receipt and review by the receiving specialty care clinicians.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
We recommended the Director of Veterans Integrated Service Network 6 establish a mechanism to routinely audit closed consults to ensure they are in accordance with Veterans Health Administration consult business rules, and take corrective actions as needed based on audit results.
Evaluation of Human Immunodeficiency Virus Screening in Veterans Health Administration Outpatient Clinics
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15-04925-469

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinical staff offer HIV screening as part of routine medical care and that managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians document informed consent for HIV testing and that managers monitor for compliance. VA Office
Clinical Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana
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16-00574-151

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2018
We recommended that Environment of Care Committee meeting minutes consistently document corrective actions taken to address rounds deficiencies and consistently track actions taken in response to identified deficiencies to closure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that facility managers ensure ventilation grills and floors in patient care areas are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the facility repair rusted equipment in patient care areas or remove it from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2018
We recommended that facility managers ensure sinks in patient nourishment kitchens are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that the hemodialysis unit manager ensure sinks and floors are clean and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the hemodialysis unit manager ensure clean and dirty items are stored separately and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that the facility collect and report data on patient transfers out of the facility as required by local policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that facility managers ensure transfer notes are written by a staff/attending physician or are written by an accceptable designee and contain a staff/attending physician countersignature.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that providers include the evaluation of previous adverse events with anesthesia in the history and physical and pre-sedation assessment and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the facility implement an Employee Threat Assessment Team and that the VA Police Officer and Risk Manager consistently attend Disruptive Behavior Committee meetings.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to appeal Patient Record Flag placement.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that facility managers ensure appropriate individuals conduct debriefings after incidents of disruptive or violent behavior and monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that facility managers ensure all employees receive Level 1 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: 3/7/2018
We recommended that community based outpatient clinic/primary care clinic employees consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Healthcare Inspection – Documentation of Patient Enrollment Concerns in Home Telehealth John D. Dingell VA Medical Center Detroit, Michigan
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14-00750-143

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2017
We recommended that the Facility Director ensure that home telehealth staff be retrained and follow the Veterans Health Administration home telehealth process of care and documentation requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2017
We recommended that the Facility Director ensure that documentation accurately reflects patients’ home telehealth enrollment status as described in this report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the Facility Director review the circumstances surrounding the entry of Home Telehealth Program monthly monitor notes in electronic health records of patients discussed in this report with the Office of Human Resources and the Office of General Counsel and take appropriate action as necessary.
Audit of VBA’s Automated Burial Payments
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15-01436-456

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/27/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, review the improper payments identified in this report and take appropriate corrective actions when warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, strengthen controls to ensure intended recipients meet entitlement requirements before authorizing automated burial payments.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 2/8/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with the requirement under the United States Code of Federal Regulations that proof of death be submitted prior to the release of automated burial payments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/27/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with United States Code of Federal Regulations related to automated burial payments and recipients’ entitlement requirements prior to authorizing payments.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 6/13/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, ensure quality assurance reviews determine whether staff inappropriately discontinued veterans’ disability benefits and assess whether spouses met entitlement requirements to receive automated burial payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 28,000,000.00
Healthcare Inspection – Echocardiography Scheduling and Quality of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois
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15-01900-142

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2017
We recommended that the Facility Director ensure that routine, outpatient echocardiography studies are scheduled in accordance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2017
We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) for possible disclosure to the patient with delayed echocardiography described in this report and take appropriate action, if any.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2017
We recommended that the Facility Director ensure that echocardiography technicians are offered opportunities for re-training and continuing education to improve the quality of the echocardiography image acquisition.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2017
We recommended that the Facility Director ensure that cardiology managers establish performance improvement activities for the echocardiography technicians in accordance with facility policy.
Review of Alleged Improperly Sole Sourced Ophthalmology Service Contracts at the Phoenix VA Health Care System
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15-01818-213

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2017
We recommended the Procurement and Logistics Office, Service Area Office West Director ensure Network Contracting Office 18 contracting officers maintain required contracting documentation in the Electronic Contract Management System, as required by VA Procurement Policy Memorandum, Mandatory Usage of VA's Electronic Contract Management System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended the Phoenix VA Health Care System Director ensure the just over $12.4 million in unauthorized commitments are ratified in accordance with VA Directive 7401.7, Unauthorized Commitments and Ratification.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2017
We recommended the Phoenix VA Health Care System Director develop a business case to evaluate the hiring of VA ophthalmologists and the use of Non-VA Care options, such as the Patient-Centered Care Program and as defined in the Veterans Access, Choice, and Accountability Act.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2017
We recommended the Phoenix VA Health Care System Director ensure staff are aware of Federal Acquisition Regulation sections 6.301 and 3.101-1 related to sole-source contracting and standards of conduct.
Review of Alleged Waste of Funds on a Cloud Brokerage Service Contract
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15-02189-336

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology implement improved controls to ensure the effective oversight of information technology projects and compliance with information technology project management procedures in order to ensure delivery of value.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology enforce the use of the Project Management Accountability System or Veteran-focused Integration Process on all Office of Information and Technology software development projects to ensure that such efforts will provide an adequate return on investment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology establish oversight mechanisms to ensure all VA-developed software costs are funded with Information Technology Systems appropriations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,300,000.00
Review of Alleged Human Resources Delays at the Atlanta VA Medical Center
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15-03401-76

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2018
We recommended the Medical Center Director assess the human resources program at the Atlanta VA Medical Center to develop an action plan to ensure all medical center staff have appropriate background investigations and determinations are accurately recorded.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2017
We recommended the Medical Center Director ensure all suitability adjudicators receive the mandatory training and background investigation required for the position.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2017
We recommended the Medical Center Director provide training to all human resources staff on the requirements of the personnel suitability program to include generally accepted resources and tools to standardize the processing of background investigations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2017
We recommended the Medical Center Director ensure the Atlanta VA Medical Center human resources staff, to include the Drug-Free Workplace Program Coordinators and Medical Review Officers, are properly trained on the requirements of the Drug-Free Workplace Program and the responsibilities of their positions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2017
We recommended the Medical Center Director review the Drug-Free Workplace Program on a regular basis to ensure compliance with regulations and that employees hired during screening gaps are subject to corrective testing.
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