Date Issued
|
Report Number
14-04819-394
All Reports
Date Issued
|
Report Number
11-02258-378
Date Issued
|
Report Number
11-04093-379
Date Issued
|
Report Number
12-01041-381
Date Issued
|
Report Number
12-01081-382
Date Issued
|
Report Number
12-03705-383
Date Issued
|
Report Number
16-02729-350
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/14/2017
We recommended the Veterans Integrated Service Network 10 Acting Director require the Detroit VA Medical Center strengthen policy to ensure the proper equipment is purchased at the appropriate time when planning projects requiring the purchase of equipment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/1/2017
We recommended the Veterans Integrated Service Network 10 Acting Director ensure the Detroit VA Medical Center develop and implement a plan to use the purchased televisions or make them available to other VA facilities to use.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended the Veterans Integrated Service Network 10 Acting Director consult with the appropriate VA financial and legal officials to determine whether the Detroit VA Medical Center violated the bona fide needs rule, and if a violation occurred, take the steps necessary to remedy the violation.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 311,544.00
Date Issued
|
Report Number
14-04361-348
Date Issued
|
Report Number
15-03688-304
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 1/12/2017
We recommend the Interim Assistant Secretary for Management strengthen controls to ensure facility officials inform officials in the contracting office of potential conflicts between solar panel projects and other projects.
No. 2
to Office of Management (OM)
Closure Date: 8/3/2016
We recommended the Interim Assistant Secretary for Management identify and share best practices for executing timely interconnection agreements with utilities based on continued collaboration with other Federal agencies.
No. 3
to Office of Management (OM)
Closure Date: 6/1/2017
We recommended the Interim Assistant Secretary for Management implement controls to periodically compare actual and expected solar power generation data to ensure the solar panel system is performing as planned.
No. 4
to Office of Management (OM)
Closure Date: 8/3/2016
We recommended the Interim Assistant Secretary for Management conduct a lessons learned assessment for solar project delays and implement additional controls to ensure future solar panel projects are properly planned and managed.
Date Issued
|
Report Number
14-02190-293
Date Issued
|
Report Number
15-04231-223
Date Issued
|
Report Number
16-02197-339
Date Issued
|
Report Number
16-01613-326
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration establishes system-wide requirements for competency assessment and validation, including frequency, for nursing employees who provide post-anesthesia care after operational hours.
Date Issued
|
Report Number
15-04248-305
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Malcom Randall VA Medical Center Director develop and implement a quality review process to ensure staff only award purchase orders for modular ramps that are Americans with Disabilities Act compliant and perform follow-up with vendors to ensure installed ramps comply with the Americans with Disabilities Act.
No. 2
to Veterans Health Administration (VHA)
We recommended the Malcom Randall VA Medical Center Director develop a formal plan to identify training needs of staff responsible for purchasing modular ramps and ensure staff are trained periodically and appropriately.
No. 3
to Veterans Health Administration (VHA)
We recommended the Malcom Randall VA Medical Center Director update written procedures to reflect the requirement that staff ensure vendor compliance with Americans with Disabilities Act standards for installed modular ramps.
No. 4
to Veterans Health Administration (VHA)
We recommend the Malcom Randall VA Medical Center Director formally require vendors to provide modular ramp measurements in bid submissions and post-installation photographs.
Date Issued
|
Report Number
13-02255-276
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and issue bills of collection to recover improper payments made to veterans while they were incarcerated.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and take action to make appropriate benefits adjustments and issue bills of collection to recover improper payments for veterans currently incarcerated in Federal penal institutions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on the Federal incarceration adjustment workload by using monthly data on Federal incarcerations to make appropriate and timely compensation and pension benefits adjustments.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/24/2016
We recommended the Acting Under Secretary for Benefits monitor the terms of the current agreement with the Bureau of Prisons and take timely action to extend the agreement when appropriate.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on state and local incarceration adjustment workload by initiating timely development action after receiving notifications of incarceration from the Social Security Administration.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase priority of state and local incarceration adjustment workload by making timely incarceration adjustments and issue bills of collection to recover improper payments, as appropriate, after providing due process notification to veterans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 307,900,000.00
Date Issued
|
Report Number
15-01296-203
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Date Issued
|
Report Number
16-00028-337
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the clinic manager ensures the risk of
infection is minimized when storing and disposing of medical waste at the Childress VA
Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that the clinic manager ensures that exit
routes are unobstructed at the Childress VA Clinic.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that staff at the Childress VA Clinic protect and secure patient-identifiable information.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Childress VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/15/2017
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/15/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that clinicians consistently provide and document interventions for clinically significant abnormal laboratory results.
Date Issued
|
Report Number
15-01887-282
Date Issued
|
Report Number
16-00116-323
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
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. 3
to Veterans Health Administration (VHA)
Closure Date: 4/25/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that facility managers ensure employees follow facility policy for disinfecting exam tables after each patient use and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that facility managers ensure annual competency assessment for pharmacy employees who prepare compounded sterile products includes a written test and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
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. 8
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the Suicide Prevention Coordinators consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that nurse managers accurately monitor the nurse staffing methodology implemented in March 2013 and use the standard nursing hours per patient day calculation to assess nurse staffing adequacy for all units.
Date Issued
|
Report Number
15-03867-287
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to improve Emergency Department access and flow during times of increased demand.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to decrease the number of patients who leave the Emergency Department without being seen by a provider.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director review current verbal communication practices in the Emergency Department and determine what steps are reasonable to safeguard patient information.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director assess Emergency Department medication prescription delivery practices to identify potential opportunities to improve pharmacy services.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure all patients in the Radiology Department are supervised.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director assess Environmental Management Services staffing needs and take appropriate actions.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure environment of care concerns identified in this report are corrected and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure Allergy Clinic staff use standard precautions when disposing used thermometer covers and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure patients receive recommended preventive medications or are offered substitutions if the medication is not on the VA National Formulary.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Minneapolis VA Health Care System Director ensure that test results are communicated to patients as required.