All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Greater Los Angeles Healthcare System, Los Angeles, California
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16-00010-302

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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16-00020-303

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days.
Review of Alleged Manipulation of Quality Review Results at VA Regional Office San Diego, CA
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15-02376-239

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Alleged Lack of Access Controls for VA's Project Management Accountability System (PMAS) Dashboard
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15-02459-260

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Alleged Improper Management of Dermatology Requests, Fayetteville VA Medical Center, Fayetteville, North Carolina
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14-02890-286

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Alleged Lack of Audit Logs for the Veterans Benefits Management System
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15-03802-222

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
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16-00108-274

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Alleged Data Manipulation of Appealed Claims at VA Regional Office Wichita, Kansas
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15-03581-204

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Review of Potential Inappropriate Split Purchasing at VA New Jersey Health Care System
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11-00826-261

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2017
We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review of VA New Jersey Health Care System purchase card transactions from December 2012 through May 2014 and require cardholders to initiate ratification for identified unauthorized commitments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2017
We recommended the Interim Director of Veterans Integrated Service Network 3 develop a plan to ensure the VA New Jersey Health Care System complies with VA purchase card program policies and internal controls, to include prioritizing required annual audits of cardholder purchases and establishing service contracts when appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended the Interim Director of Veterans Integrated Service Network 3 hold VA New Jersey Health Care System purchase cardholders, supervisors, and approving officials accountable for policy violations, to include taking appropriate administrative action, if warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2019
We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review of VA New Jersey Health Care System purchase card transactions for building renovations and take corrective action for all identified inappropriate transactions.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 8,900,000.00
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Sheridan VA Healthcare System, Sheridan, Wyoming
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15-05154-271

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that employees at the Afton CBOC receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2016
We recommended that the Facility Director ensures that a policy/procedure is in place for the identification of individuals entering the Afton CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that the clinic manager ensures that Afton CBOC employees receive the required hazardous communications training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2016
We recommended that the Facility Director ensures there is a policy/procedure for the cleaning and disinfection of telehealth equipment at the Afton CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that clinicians document assessments and treatment plans for Home Telehealth patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe required by VHA.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that acceptable providers document plans of care and disposition for patients with positive PTSD screens.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Combined Assessment Program Review of the James H. Quillen VA Medical Center, Mountain Home, Tennessee
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16-00112-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Domiciliary Care for Homeless Veterans Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband and that program managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document daily resident room inspections for unsecured medications and that program managers monitor compliance.
Combined Assessment Program Summary Report – Evaluation of Safe Medication Storage Practices in Veterans Health Administration Facilities
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16-00693-269

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities’ policies include automated dispensing machine user training and competency assessment requirements and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees perform and document monthly inspections of all medication storage areas and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when employees identify deficiencies during medication storage area inspections, they document corrective actions and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities have oral syringes available for medication administration and clearly label and store them separately from parenteral syringes and that facility managers monitor compliance.
Review of Community Based Outpatient Clinic and Other Outpatient Clinics of Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
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16-00017-245

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that managers monitor hand hygiene compliance at the Selma VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2016
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Review of VBA’s Alleged Inappropriate Prioritization of Appeals at VARO Roanoke, VA
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15-02384-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/19/2016
We recommended that the Roanoke VA Regional Office Director ensure that leadership and appeals staff follow the workload management plan to prioritize work based on the appeals pending the longest.
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