Date Issued
|
Report Number
15-01653-226
All Reports
Date Issued
|
Report Number
15-04516-229
Open
Closed-Implemented
Closed-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
Date Issued
|
Report Number
15-04681-228
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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.
Date Issued
|
Report Number
16-04882-216
Date Issued
|
Report Number
14-02890-409
Date Issued
|
Report Number
14-02890-116
Date Issued
|
Report Number
14-02890-93
Date Issued
|
Report Number
14-03368-97
Date Issued
|
Report Number
14-02890-126
Date Issued
|
Report Number
14-02890-129
Date Issued
|
Report Number
14-02890-112
Date Issued
|
Report Number
14-02890-96
Date Issued
|
Report Number
14-02890-127bbb