All Reports

Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
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16-00107-256

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove outdated commercial supplies from patient care areas and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure operating rooms are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace damaged furniture in the operating rooms.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the competency assessment policy for employees who prepare compounded sterile products to include the required intervals for gloved fingertip sampling.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the compounded sterile products safety policy to include verification of all finished compounded sterile products by a pharmacist.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees perform and document cleaning of storage shelving and bins in all compounding areas and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide discharge instructions to patients and/or caregivers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a plan for transition to the allowed note titles.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees use the required advance directive note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the mammography services policy includes all required elements.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Controlled Substances Coordinator ensure all required non-pharmacy areas with controlled substances are inspected and monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility strengthen processes to ensure weekly inventories of automated dispensing machines are consistently conducted and that facility managers monitor compliance.
Review of Alleged Noncompliance With Section 508 of the Rehabilitation Act on MyCareer@VA Web Site
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15-02781-153

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration correct all Section 508 compliance issues with the MyCareer@VA Web site and seek certification of Section 508 compliance from the appropriate component within VA Section 508.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration develop and implement a process to ensure their products conform with Section 508 requirements prior to their deployment, which includes defining what support is required to document a product¿s compliance with Section 508 requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration provide and require training for all individuals involved in developing and maintaining products to ensure they are aware of the requirements and expectations for conformance with Section 508 requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/22/2019
We recommended the Assistant Secretary for Information and Technology strengthen policy to ensure Electronic and Information Technology products are compliant with Section 508 prior to their deployment, which includes providing an expectation of when to establish compliance, how to document compliance, and what specifically constitutes compliance with Section 508.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 34,011.00
Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri
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15-04695-231

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility replace missing/stained ceiling tiles in patient care areas.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that facility managers ensure all patient care areas have secure storage for protected health information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility assess the possible subfloor penetration and replace missing and broken floor tiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that facility managers ensure employees perform and document daily floor and monthly storage shelving cleaning in all compounding areas and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Audit of VA's Conference Management for Fiscal Year 2014
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15-01227-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address if and when a Conference Package may be used to summarize the budgets for multiple events and how to present the budget for each event to ensure adequate line item detail for each event.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address how to present line item detail of expenditures in the Final Conference Reports if the approved Conference Package was for multiple events to ensure traceability to source documents.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management establish review procedures that ensure Conference Packages and Final Conference Reports comply with law and VA policy and report the results to the Deputy Secretary or VA Chief of Staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to provide adequate accountability to ensure that VA organizations comply with conference policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Conference Certifying Official as the reviewer of the Conference Package instead of the Responsible Conference Executive.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Corporate Travel Reporting Office review of Conference Packages with a budget of $100,000 or more before submitting the package for Deputy Secretary or Secretary approval.
Combined Assessment Program Review of the Fargo VA Health Care System, Fargo, North Dakota
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16-00104-230

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes gloved fingertip sampling.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that facility managers ensure all compounded sterile product labels contain the preparer and checker initials and the beyond use date.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that physicians consistently document discharge progress notes or instructions that include all required elements and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility manager’s monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that clinicians include documentation of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
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