Date Issued
|
Report Number
14-02890-413
All Reports
Date Issued
|
Report Number
15-05180-75
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Facility Director implement strategies to enhance communication and coordination across clinical areas for patients with High Risk for Suicide Patient Record Flags.
Date Issued
|
Report Number
14-02890-72
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended the VA Desert Pacific Healthcare Network Director review the training records of all SAVAHCS schedulers to ensure their training is compliant with Veterans Health Administration scheduling policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended the VA Desert Pacific Healthcare Network Director ensure that SAVAHCS schedulers comply with current VHA policy regarding scheduling policies and practices.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended the VA Desert Pacific Healthcare Network Director perform an administrative investigation to determine who directed former Business Service Line officials to create and use training materials that did not comply with VA scheduling policy and take appropriate disciplinary action for any individuals involved.
Date Issued
|
Report Number
14-02890-353
Date Issued
|
Report Number
14-02890-412
Date Issued
|
Report Number
15-05255-422
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/2/2016
We recommended the Under Secretary for Health ensure the Consolidated Mail Outpatient Pharmacies¿ Logistics Officer and Director or Associate Director review all inventory adjustments and approve adjustment documentation monthly as required by CMOP Inventory Management and Control national policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/2/2016
We recommended the Under Secretary for Health ensures Consolidated Mail Outpatient Pharmacy National Office implements a mechanism to validate self-reported data to ensure the reliability of its core quality metrics.
Date Issued
|
Report Number
14-04898-290
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the Veterans Integrated Service Network Director conduct a quality review of the imaging study interpretations completed during the time of the unsigned Memorandum of Understanding referenced in this report.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the System Director strengthen processes to ensure the Radiology Services is fully integrated into the system's formal peer review program.
Date Issued
|
Report Number
15-00506-420
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/17/2017
We recommended that the System Director strengthen processes to ensure staffing levels are analyzed and documented in applicable safety and quality of care reviews and annually reported to leadership.
Date Issued
|
Report Number
14-02890-425
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended the W.G. (Bill) Hefner VA Medical Center Directorrequire staff to review all unscheduled radiology exam orders that are30 days past the clinically indicated date and either cancel the orders ifthe exams are not needed or ensure the exams are scheduled.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended the W.G. (Bill) Hefner VA Medical Center Directormake unscheduled urgent and STAT (immediate) orders a priority in thestaff’s review of unscheduled radiology orders and ensure staff determinewhether any potential harm has occurred to patients due to the delays incare.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/4/2016
We recommended the VA Mid-Atlantic Health Care Network Directorensure that the W.G. (Bill) Hefner VA Medical Center develops a plan toaddress existing demand for Radiology exams and ensures future patientsreceive access to exams in accordance with VHA policy.
Date Issued
|
Report Number
15-04672-342
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health update the Veterans Health Administration Consult Policy.
No. 2
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System communicate consult policies and procedures to all facility staff and providers to ensure consistent procedures and responsibilities to effectively manage and schedule consults.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System develop a routine review of closed consults to ensure staff are appropriately discontinuing and documenting consults in accordance with national and local policy.
No. 4
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure respective services follow up with the patients identified in this review for appropriate action.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Chiropractic Services review all consults canceled by the service since January 1, 2015, for appropriate action.
No. 6
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System ensure that the care of the patient identified in the reported case summary is evaluated, takes action, if appropriate, and confers with Regional Counsel regarding the appropriateness of disclosures to patients and families.
No. 7
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System develop a mechanism to ensure that Quality, Safety, and Improvement services appropriately review deceased patients’ records with an open consult, and staff timely and appropriately close the consult upon verification of death by Decedent Affairs.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure services assign and maintain appropriate and sufficient clinical staff to receive and review consults within target time frames.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Human Resources and specialty care services fill vacant medical support assistant positions responsible for scheduling consults in specialty care services to ensure sufficient resources to manage and schedule consults.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System pursue an automated process to ensure Vascular Lab results are entered in the electronic medical records in order to eliminate reliance on printed lab results.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Vascular Service review all incomplete Vascular Lab consults to identify and address all potential lost lab results.
No. 12
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure clinics coordinate with clinic informatics services to develop a mechanism to routinely identify and address open consults in which the corresponding appointment was already completed.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/27/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System assign sufficient staff to manage non-VA care and Choice consults and appointments.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/10/2017
We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure non-VA care develop a process to routinely follow up with those patients with open community care consults older than 120 days to determine if they received the requested care.
Date Issued
|
Report Number
14-02890-255
Date Issued
|
Report Number
15-00650-423
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 12 Acting Director ensure management at the William S. Middleton Veterans Hospital complies with the facility policy requiring all equipment requests contain sufficient and accurate information to justify the acquisition request.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/26/2017
We recommended the Veterans Integrated Service Network 12 Acting Director ensure all laser lead extractors within the Veterans Integrated Service Network are being utilized to the extent possible.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 409,771.00
Date Issued
|
Report Number
15-00084-370
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
We recommended that the Facility Director ensure that recommendations, if any, from other reviews of the surgical program be implemented.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/2/2017
We recommended that the Facility Director implement procedures to ensure patients are adequately evaluated by medicine and anesthesia providers prior to surgery.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the Facility Director ensure that peer reviews are conducted as required when criteria are met.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the Facility Director implement processes to ensure that necessary surgical supplies, equipment, and instruments are available, functional, and duplicated as needed.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that the Facility Director evaluate the organizational structure for parity concerning surgical technician positions.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/2/2017
We recommended that the Facility Director ensure that the surgical post-operative clinic uses the same nurse staffing methodology as other outpatient clinics.
Date Issued
|
Report Number
14-05118-147
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/19/2017
We recommended the Acting Under Secretary for Benefits improve outreach by periodically requiring Education Liaison Representatives to review Post-9/11 G.I. Bill and Yellow Ribbon Program requirements, the School Certifying Official Handbook, and other available Veterans Benefits Administration training resources with School Certifying Officials to help them submit accurate and complete tuition and fee certifications.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits develop risk profiles for schools that are prone to certification problems, improper payments, and missed recoupments; and implement a process to periodically review and verify the certification information submitted by these schools.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits incorporate improper payment and missed recoupment risk factors into Veterans Benefits Administration’s risk-based system for the prioritization and completion of compliance surveys.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 5/23/2017
We recommended the Acting Under Secretary for Benefits revise the School Certifying Official Handbook to clarify guidance on allowable book and supply fees.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2017
We recommended the Acting Under Secretary for Benefits review and strengthen Education Service policies and controls regarding the discontinuance and recoupment of payments, repeated classes, and satisfactory academic progress to ensure compliance with Federal regulations and prevent possible education benefits abuse.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2017
We recommended the Acting Under Secretary for Benefits ensure that mitigating circumstances are properly verified and supporting documentation is obtained before tuition repayments are forgiven.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits initiate action to recover identified improper payments when collections are deemed appropriate and reasonable.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2016
We recommended the Acting Under Secretary for Benefits review the identified missed recoupments to determine if collections would be appropriate and reasonable.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,270,000,128.00
Date Issued
|
Report Number
14-00875-325
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/30/2016
We recommended that the System Director ensure that primary care providers are notified of specialty evaluations and treatment plans so they can be involved in care coordination.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the System Director ensure that staff assesses patient learning needs, barriers, abilities and readiness to learn, and that related education is provided as required by local policy, and monitor for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/26/2017
We recommended that the System Director ensure that all patients are annually screened for depression, or more frequently as indicated by existing or newly identified risks, and that system manager’s monitor for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the System Director ensure that documentation from non-VA clinical care, including radiology reports, are obtained and available in the electronic health record for review in a timely and consistent manner.
No. 5
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that system staff place consults with urgency based on the needed response time.
No. 6
to Veterans Health Administration (VHA)
We recommended that the System Director review facility service agreements and care coordination in order to better care for patients with complex diseases that require multi-specialty intervention.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/26/2017
We recommended that the System Director review this case and consult with the Office of Chief Counsel (formerly Regional Counsel) regarding the care provided and take action if appropriate.
Date Issued
|
Report Number
15-01982-113
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that primary care providers are able to assess, treat, monitor, and reassess patients on chronic opioid therapy within the appropriate timeframe.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that the Veterans¿ Integrated Pain Management Clinic meets non-opioid pain management needs of patients as evidenced by timely consultation completions.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director consider the clinical and administrative demands of chronic opioid therapy care when determining appropriateness of primary care provider staffing and that staffing plans are in place for planned and unplanned provider vacancies and absences.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that benzodiazepine appropriateness evaluations are completed as required for chronic opioid therapy patients with post-traumatic stress disorder.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that primary care and mental health providers communicate and coordinate care for post-traumatic stress disorder patients receiving both opioids and benzodiazepines.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure regular communication between facility leadership and community based outpatient clinic leadership to support consistent high quality care.
Date Issued
|
Report Number
14-04274-418
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director charter a team to evaluate the facility's entire process involving reusable medical equipment in accordance with applicable guidelines, integrate reviews' recommendations, and develop an overarching reusable medical equipment management plan.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable national and local policies and guidelines for the reprocessing of reusable medical equipment and the preparation of trays and instrument lists.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable guidelines to record daily temperature and humidity levels in Sterile Processing Service areas and act upon and document actions when temperature and humidity levels are out of range.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure that an ergonomic assessment be made of the physical access and weight of items stored in the operating room Sterile Processing Service storage area and ensure staff safety and compliance with applicable Occupational Safety and Health Administration standards.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure training of operating room staff in proper handling of sterile packages and establish a formal process to track and trend issues with packages.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure adequate staffing to manage the operational requirements of Sterile Processing Service.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure that the operating room and Sterile Processing Service staff implement a reusable medical equipment quality control program consistent with Veteran Health Administration guidelines.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director implement measures to improve collaboration and communication within and between operating room and Sterile Processing Service staff.
Date Issued
|
Report Number
15-02707-277
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to prevent staff from completing a decision without considering potential eligibility to statutory housebound benefits any time a veteran has a single 100 percent evaluation.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2018
We recommended the then Acting Under Secretary for Benefits conduct a review of all veterans being paid compensation at the housebound rate with a combined evaluation of 90 percent or less and provide certification of completion of the review to the Office of Inspector General.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits establish a plan to conduct periodic reviews of high-risk cases in which housebound benefits are being paid.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits implement a plan to provide all decision-makers the updated special monthly compensation training and monitor the effectiveness of the training.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to ensure staff discontinue temporary housebound benefits when the criteria are no longer met.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/15/2017
We recommended the then Acting Under Secretary for Benefits remind staff of the requirements to use the Special Monthly Compensation Calculator in all special monthly compensation cases and include the results in the file, and implement a plan to ensure compliance.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits clarify the meaning of the term substantially confined for housebound in-fact benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 154,400,000.00
Date Issued
|
Report Number
16-00351-453
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health ensure that the Veterans Health Administration develops staffing models for critical need occupations, and we further recommend that the Veterans Health Administration sets forth milestones and a timetable for further critical need occupations’ staffing model development, piloting, and implementation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health review data on regrettable losses and consider implementing measures to reduce such losses.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health consider incorporating data that predicts changes in veteran demand for health care into its staffing model.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health assess the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
Date Issued
|
Report Number
15-00018-349
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/27/2016
We recommended that the Facility Director ensure that all patients who experienced delays in notifications of positive fecal immunochemical tests are assessed to determine if appropriate follow-up care was rendered and whether the delays adversely affected the patients¿ clinical outcomes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/27/2016
We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) regarding the care of the four patients described in this report and any additional patients identified in further review who may have been adversely affected, to determine the appropriate action to take, if any.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that the Facility Director ensure that providers communicate positive colorectal cancer screening results to patients and document notifications in electronic health records according to Veterans Health Administration test notification policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that the Facility Director ensure that processes are in place to monitor providers’ compliance with Veterans Health Administration colorectal cancer screening policy.