Date Issued
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Report Number
14-02890-296
All Reports
Date Issued
|
Report Number
15-02747-314
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 10/20/2017
We recommend that the VA Deputy Secretary confer with the Offices of General Counsel and Human Resources Management to develop VA policy related to the staffing and recruitment of VLJs, incorporate it into proper guidance and a requirement to sign a confidentiality agreement, provide applicability of the Privacy Act, a clear definition of what is confidential, and ensure that policy is implemented.
Date Issued
|
Report Number
16-00024-299
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Date Issued
|
Report Number
15-04252-284
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/6/2017
We recommended the Under Secretary for Health ensure implementation of the corrective action plans included in VA’s Agency Financial Report to make procurement practices for the VA Community Care and Purchased Long Term Services and Support programs compliant with laws and regulations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Under Secretary for Health implement steps to achieve reduction targets or appropriately adjust them for the VA Community Care, Purchased Long Term Services and Support, Beneficiary Travel, and Supplies and Materials programs.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/2/2017
We recommended the Acting Under Secretary for Benefits implement steps to achieve reduction targets or appropriately adjust them for the Compensation, Education Chapter 1606, and Education Chapter 1607 programs.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/2/2017
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, implement steps to achieve reduction targets for the Disaster Relief Act-Hurricane Sandy program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Under Secretary for Health implement additional training for personnel who evaluate Improper Payment Elimination and Recovery Act samples for the Supplies and Materials program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended the Under Secretary for Health provide contracting expertise to the Improper Payment Elimination and Recovery Act review team, as needed.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 3/3/2017
We recommended the Acting Under Secretary for Benefits develop a solution for correcting the concurrent payment of Compensation and Pension benefits and military drill pay and seek Office of Management and Budget assistance in coordinating a future resolution of the matter.
Date Issued
|
Report Number
16-00025-301
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended that managers ensure that Milledgeville VA Clinic staff participate in emergency management training and exercises.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/12/2016
We recommended that the clinic manager ensures that Milledgeville VA Clinic and contracted employees receive the required hazardous communications training.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended that the Milledgeville VA Clinic manager ensures that there are no expired injectable medication vials.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/12/2016
We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/14/2017
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/14/2017
We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Date Issued
|
Report Number
15-04704-297
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas and furnishings and equipment in patient care areas are clean and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
We recommended that facility managers initiate actions to repair damaged furnishings and equipment in patient care areas or remove them from service.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/30/2017
We recommended that the facility consistently monitor temperature in the inpatient pharmacy compounding buffer areas and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees perform and document monthly cleaning of storage shelving in all compounding areas and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/5/2017
We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
We recommended that facility managers develop a temporary bed location policy.
No. 8
to Veterans Health Administration (VHA)
We recommended that the Facility Director appoint a Bed Flow Coordinator with a clinical background.
No. 9
to Veterans Health Administration (VHA)
We recommended that physicians consistently document discharge progress notes or instructions that include all required elements and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that the facility develop a computed tomography policy and procedures that include all required components.
No. 11
to Veterans Health Administration (VHA)
We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented annual radiation safety training.
No. 12
to Veterans Health Administration (VHA)
We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
We recommended that facility managers ensure new clinical employees complete suicide risk management training within the required timeframe and monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 5/5/2017
We recommended that the Suicide Prevention Coordinator provide at least five community outreach activities every month and maintain documentation of these activities and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
We recommended that clinicians consistently assess patients for suicide risk prior to placing a high risk for suicide flag and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
We recommended that clinicians not place flags in the electronic health records of moderate- and low-risk patients and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 5/5/2017
We recommended that clinicians include the contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
We recommended that facility managers establish a mammography services policy.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 6/30/2017
We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 5/5/2017
We recommended that facility managers ensure ordering clinicians receive signed written mammography reports within 30 days of the procedure date and monitor compliance.
No. 24
to Veterans Health Administration (VHA)
We recommended that Controlled Substances Coordinator provide the Facility Director with controlled substances inspection quarterly trend reports.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 5/5/2017
We recommended that acute care employees provide pressure ulcer education to patients at risk for or with pressure ulcers and/or their caregivers and document the education and that facility managers monitor compliance.
No. 26
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology implemented in August 2013.
Date Issued
|
Report Number
16-00020-303
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that managers monitor hand hygiene compliance at the Monroe County VA Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Facility Director ensures annual review of the Hazard Vulnerability Assessment for the Monroe County VA Clinic.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the clinic manager ensures that sterile commercial supplies at the Monroe County VA Clinic are not expired.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the clinic manager reviews the Monroe County Clinic's hazardous materials inventory twice within a 12-month period.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Monroe County VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that clinicians document contact with patients to evaluate suitability for Home Telehealth services.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days.
Date Issued
|
Report Number
16-00010-302
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended that employees at the Gardena VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended that managers ensure that staff at the Gardena VA Clinic participate in emergency management training and exercises.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended that the clinic manager ensures that Gardena VA Clinic employees receive the required hazardous communications training.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended that the clinic manager review the Gardena VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/14/2017
We recommended that the Facility Director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Date Issued
|
Report Number
15-01599-289
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the System Director ensure adequate consultation, formalized back up, and contingency plans for specialties with limited specialty provider availability.
Date Issued
|
Report Number
16-00101-300
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that the senior-level committee responsible for key quality, safety, and value functions be chaired or co-chaired by the Facility Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
We recommended that Physician Utilization Management Advisors 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: 12/15/2016
We recommended that facility managers consistently follow actions taken when data analyses indicated problems or opportunities for improvement to resolution in the Inpatient Operations Council, Medical Executive Committee, and Medical Records Committee.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/17/2018
We recommended that senior managers become involved in quality, safety, and value activities.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/18/2017
We recommended that employees secure medication carts and automated dispensing machines when not in use and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility managers ensure pharmacy technicians complete all competency components annually and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that employees monitor temperature in the compounding areas at the Sepulveda pharmacy and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that employees monitor temperature in the compounding areas at the Sepulveda pharmacy and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility managers ensure new non-clinical employees receive suicide prevention training and new clinical employees receive suicide risk management training and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that employees complete the required reports and reviews regarding patients who attempt or complete suicide and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/18/2017
We recommended that clinicians include contact numbers of family or friends for support and assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 3/15/2017
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
We recommended that treatment teams follow up with patients at least four times during the first 30 days after discharge and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 3/11/2019
We recommended that the Medical Records Committee provide oversight and coordination of the review of the quality of entries in electronic health records.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that representatives from Surgery Service consistently attend Blood Usage Committee meetings.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that facility managers ensure all designated employees complete annual N95 respirator fit testing and monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that facility managers initiate actions to address identified security deficiencies and ensure correction of all deficiencies identified during annual physical security surveys.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 12/15/2016
We recommended that facility managers ensure all patients discharged with pressure ulcers receive dressing supplies prior to being discharged and monitor compliance.
Date Issued
|
Report Number
15-02459-260
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology create read-only access capability for the Project Management Accountability System.
No. 2
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology assess the current level of each user’s access to the Project Management Accountability System Dashboard to ensure each user’s access is based on the least privilege needed.
No. 3
to Information and Technology (OIT)
Closure Date: 1/3/2018
We recommended the Assistant Secretary for Information and Technology develop Project Management Accountability System Dashboard access logs.
No. 4
to Information and Technology (OIT)
Closure Date: 4/3/2018
We recommended the Assistant Secretary for Information and Technology periodically review Project Management Accountability System Dashboard access logs to ensure users have a need for system access.
Date Issued
|
Report Number
15-02376-239
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/9/2016
We recommended that the San Diego VA Regional Office Director develop and implement a plan that provides management oversight to ensure staff comply with local policy to correct individual quality review errors.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/9/2016
We recommended that the San Diego VA Regional Office Director develop and implement a plan to ensure staff work through the remaining backlog of individual quality review errors pending correction.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 5/9/2016
We recommended that the Under Secretary for Benefits establish a timeliness standard in which claims processing staff at VA Regional Offices are expected to correct errors identified by Quality Review Team staff.
Date Issued
|
Report Number
14-02890-268
Date Issued
|
Report Number
15-01951-281
Date Issued
|
Report Number
14-04310-280
Date Issued
|
Report Number
14-02890-291
Date Issued
|
Report Number
14-02890-286
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the facility Director follow up on the 143 patients referenced in this report who did not receive dermatology care after their appointments or consults were cancelled, and take appropriate action.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the facility Director follow up on all the patients with cancelled dermatology appointments and consultations in 2011–2012 who were not subsequently seen by a dermatology provider to determine whether the requested evaluation and/or care is still needed.
Date Issued
|
Report Number
15-03802-222
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 12/20/2016
We recommended the Acting Under Secretary for Benefits develop and provide the Office of Information and Technology with system requirements for integrating audit logs containing the data security officers need to intervene in potential security violations into the Veterans Benefits Management System.
No. 2
to Information and Technology (OIT)
Closure Date: 6/25/2018
We recommended the Assistant Secretary for Information and Technology integrate audit logs into the Veterans Benefits Management System based on the requirements provided by the Acting Under Secretary for Benefits.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 6/25/2018
We recommended the Acting Under Secretary for Benefits test the newly integrated audit logs to ensure that the logs capture all potential security violations.
Date Issued
|
Report Number
16-00108-274
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/22/2017
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. 2
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that the facility annually assess the competency of pharmacy employees who prepare compounded sterile products and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/1/2017
We recommended that facility managers ensure employees perform and document monthly cleaning of storage shelving in all compounding areas and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that the facility revisethe radiation safety policy to include a computed tomography quality control program with annual program monitoring by a medical physicist, image quality monitoring, and scanner maintenance; computed tomography protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer; a process for managing/reviewing computed tomography protocols and procedures to follow when revising protocols; and radiologist review of appropriateness of computed tomography orders.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that facility managersconfirm computed tomography technologists have computed tomography certification prior to hiring them and ensure all current computed tomography technologists hired after July 1, 2014, have the certification.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/23/2016
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/1/2016
We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/22/2017
We recommended that facility managers ensure Focused Professional Practice Evaluations for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/23/2016
We recommended that facility managers ensure Sterile Processing Service employees responsible for reprocessing activities receive annual competency assessments.
Date Issued
|
Report Number
15-03581-204
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/26/2016
We recommended the Wichita VA Regional Office Director ensure staff correct the 36 Notices of Disagreement established in the Veterans Appeals Control and Locator System using inaccurate data.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/25/2016
We recommended the Wichita VA Regional Office Director develop and implement a plan to provide adequate oversight to ensure staff establish Notices of Disagreement in the Veterans Appeals Control and Locator System using accurate data.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2016
We recommended the Acting Under Secretary for Benefits develop a plan to notify staff at its 56 VA Regional Offices of the modified policy, effective July 29, 2015, to ensure correct processing of appellate claims.