All Reports

Follow-Up Audit of VBA's Internal Controls Over Disability Benefits Questionnaires
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14-02384-45

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2017
We recommended the Acting Under Secretary for Benefits evaluate options for electronically capturing and analyzing information contained on completed Disability Benefits Questionnaires and implement the most cost effective option. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Acting Under Secretary for Benefits revise the remaining 59 public-use Disability Benefits Questionnaires to provide veterans and clinicians adequate notification regarding verification of submitted information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/14/2016
We recommended the Acting Under Secretary for Benefits establish policies and procedures for determining if clinicians who prepare public-use Disability Benefits Questionnaires are private or Veterans Health Administration clinicians.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/2/2018
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include steps for obtaining missing public-use Disability Benefits Questionnaires clinician information and verifying clinicians have an active medical license. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2016
We recommended the Acting Under Secretary for Benefits revise Veterans Affairs Regional Office quality assurance review methodologies to review appropriate samples of claims including public-use Disability Benefits Questionnaires.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with Disability Benefits Questionnaires’ special-issue indicator requirements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/4/2016
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with public-use Disability Benefits Questionnaires’ clinician information completeness requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/26/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2017
We recommended the Acting Under Secretary for Benefits require Veterans Benefits Administration’s Compensation Service Disability Examination Management staff to conduct annual validation reviews that select samples from a complete universe of claims with public-use Disability Benefits Questionnaires and focus on public-use Disability Benefits Questionnaires that pose an increased risk of fraud. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include follow-up actions for inadequate public-use Disability Benefits Questionnaires.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise the Systematic Technical Accuracy Review checklists and local quality assurance reviews to evaluate whether claims processors use adequate public-use Disability Benefits Questionnaires instead of obtaining unnecessary Veterans Health Administration compensation and pension examinations.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 24,000,000.00
Combined Assessment Program Review of the Edward Hines, Jr. VA Hospital, Hines, Illinois
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15-04700-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2017
We recommended that designated employees maintain a log of individuals entering the facility between 9:00 p.m. and 5:00 a.m. and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms or post signage indicating that rooms are not operational and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2017
We recommended that employees secure sensitive patient information at all times and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes an annual written test.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that facility managers ensure completion and documentation of periodic surface sampling in all required areas and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure employees perform and document monthly cleaning of ceilings, walls, and storage shelving in all compounding areas and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that the facility develop and implement a policy that addresses temporary bed locations.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that the facility revise the computed tomography quality control program to include monitoring by a medical physicist at least annually, image quality monitoring, and computed tomography scanner maintenance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Maryland Health Care System, Baltimore, Maryland
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15-05164-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Pocomoke City VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2017
We recommended that the clinic manager reviews the Pocomoke City VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director ensures that the facility’s written policy include the communication of lab results to patients no later than 14 days from the date on which the results are available to the ordering practitioner.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the VA Maryland Health Care System, Baltimore, Maryland
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15-05497-132

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that Environment of Care Committee meeting minutes reflect sufficient discussion of environment of care rounds deficiencies, corrective actions taken to address the deficiencies, and tracking of actions to closure for the three campuses and for the community based outpatient clinics.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that Acute Care and Non-Acute Care Infection Control Committee meeting minutes consistently reflect discussion of hand hygiene data, actions implemented, and follow-up on actions implemented for the three campuses.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure all health care occupancy buildings at the Baltimore and Loch Raven campuses have at least one fire drill per shift per quarter and have documented fire drill critiques and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that facility managers ensure the locked mental health unit and public bathrooms on the 3rd, 5th, and 6th floors at the Baltimore campus are frequently and thoroughly cleaned and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2017
We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms at the Baltimore and Perry Point campuses and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that employees at all three campuses promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure the Baltimore campus Emergency Department main entrance door is functional and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that dental clinic managers ensure all Baltimore campus dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that dental clinic managers ensure all Baltimore campus dental clinic employees complete hazard communication training on chemical classification, labeling, and Safety Data Sheets and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that dental clinic managers ensure designated Baltimore campus dental clinic employees complete laser safety training and monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility managers ensure operating room housekeepers complete training on cleaning and disinfection procedures.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that facility managers ensure consistent monitoring of operating room temperature and humidity and monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that facility managers ensure completion and documentation of periodic surface sampling in the inpatient pharmacy area and monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure the airflow monitoring system alarms in the compounded sterile product ante area are functional.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that facility managers ensure employees perform and document routine cleaning of laminar flow hoods, counters, floors, and storage shelving in the compounding area and monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that attending physicians consistently document a separate admission note or addendum within 1 day of the patient’s admission.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that physicians document transfer notes and that facility managers monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that employees consistently scan the most current advance directive into the electronic health record and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
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. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
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. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that clinicians include the identification of contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that clinicians ensure patients and/or family members receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Review of Alleged Wasted Funds in VHA's Southern Arizona VA Health Care System
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15-02413-55

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended the Veterans Integrated Service Network 18 Director ensure the Southern Arizona VA Health Care System develop and implement a policy requiring coordination and review of leased equipment requests with the Health Care System's support services during the acquisition process.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 217,000.00
Inspection of the VA Regional Office in Manila, Philippines
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15-05024-97

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/22/2016
We recommended the Manila VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Butler Healthcare, Butler, Pennsylvania
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15-05161-98

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that employees at the Cranberry Township 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: 2/11/2016
We recommended that managers ensure that staff at the Cranberry Township VA Clinic participate in emergency management training and exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that managers ensure that Cranberry Township VA Clinic employees receive the required hazardous communications training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that managers at the Cranberry Township VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians complete Home Telehealth enrollment consults.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Healthcare Inspection – Veterans Crisis Line Caller Response and Quality Assurance Concerns, Canandaigua, New York
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14-03540-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that issues regarding response hold times when callers are routed to backup crisis centers are addressed and that data is collected, analyzed, tracked, and trended on an ongoing basis to identify system issues.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that orientation and ongoing training for all Veterans Crisis Line staff is completed and documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that silent monitoring frequency meets the Veterans Crisis Line and American Association of Suicidology requirements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Office of Mental Health Operations Executive Director establish a formal quality assurance process, as required by the Veterans Health Administration, to identify system issues by collecting, analyzing, tracking, and trending data from the Veterans Crisis Line routing system and backup centers and that subsequent actions are implemented and tracked to resolution.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director consider the development of a Veterans Health Administration directive or handbook for the Veterans Crisis Line.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that contractual arrangements concerning the Veterans Crisis Line include specific language regarding training compliance, supervision, comprehensiveness of information provided in contact and disposition emails, and quality assurance tasks.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director consider the development of algorithms or progressive situation-specific stepwise processes to provide guidance in the rescue process.
Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California
|
15-04707-111

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility manager’s monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, include corrective actions to address those deficiencies, and track corrective actions to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Hospital Epidemiology Committee meeting minutes consistently reflect discussion of identified high-risk areas and implementation of actions to address those areas and document follow-up on actions implemented to address identified problems.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise operating room emergency fire policy and procedures to include alarm activation, evacuation, and equipment shutdown with responsibility for turning off room or zone oxygen.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes visual observation/“hands-on” skill assessment of aseptic technique and gloved fingertip sampling.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that special care unit sending nurses document transfer assessments and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended physicians consistently document discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers review the organizational alignment for the Radiation Safety Officer position to ensure compliance with Veterans Health Administration policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that facility managers develop and implement a comprehensive computed tomography policy that includes a quality control program and procedures to follow when revising computed tomography protocols.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that computed tomography technologists perform and document quality control checks, that a supervisory employee conducts periodic review to verify the checks were done, and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Inspection of the VA Regional Office Oakland, California
|
15-05023-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/27/2016
We recommended the Oakland VA Regional Office Director conduct a review of the 58 temporary 100 percent disability evaluations remaining from the inspection universe of 88, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/27/2016
We recommended the Oakland VA Regional Office Director implement a plan to ensure all claims processing staff comply with the Veterans Benefits Administration’s second-signature policy for higher levels of special monthly compensation claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/27/2016
We recommended that the Acting Under Secretary for Benefits ensure that approved higher levels of special monthly compensation training materials are updated and accurate
Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming
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15-04697-105

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2017
We recommended that Physician Utilization Management Advisors document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that the facility consistently take actions when data analyses indicate problems or opportunities for improvement and evaluate them for effectiveness in committee reviews, utilization management, and root cause analyses and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the facility conduct an annual infection prevention risk assessment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that the facility revise its policy for temporary bed locations to include priority placement for inpatient beds given to patients in temporary bed locations, upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that clinicians consistently place flags in the electronic health records of patients identified as high risk for suicide and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2016
We recommended that clinicians not place flags in the electronic health records of patients identified as moderate or low risk for suicide and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2017
We recommended that clinicians include the identification of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility managers ensure electronic health record quality reviews include a representative sample of charts from each service or program.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that facility managers ensure all non-hospice and palliative care clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility managers establish a process to track and document hospice and palliative care consults that are not acted upon within 7 days of the request.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Coatesville VA Medical Center, Coatesville, Pennsylvania
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15-05163-106

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2016
We recommended that managers provide auditory privacy for Springfield VA Clinic veterans at check-in.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2016
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2016
We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania
|
15-04708-115

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2016
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Patient Safety Manager submit an annual patient safety report to facility leaders at the completion of each fiscal year.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the facility revise its protected peer review policy to be consistent with Veterans Health Administration policy and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the Power of Women Embracing Recovery Program have a Class K fire extinguisher available in the kitchen used by residents.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Domiciliary Care for Homeless Veterans Program, Post-Traumatic Stress Disorders Residential Rehabilitation Treatment Program, and Substance Abuse Treatment Unit employees consistently perform and document contraband inspections, daily bed checks, and resident room inspections for unsecured medications and that program/unit managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Domiciliary Care for Homeless Veterans Program and Substance Abuse Treatment Unit managers ensure residents secure medications in their rooms and monitor compliance.
Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas
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15-04696-107

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that controlled substances inspectors consistently reconcile 1 day's dispensing from the pharmacy to each automated unit and that the Controlled Substances Coordinator monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure the Controlled Substances Coordinator's position description includes controlled substances oversight duties.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure controlled substances inspectors receive annual updates and refresher training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the Controlled Substances Coordinator ensure random scheduling of non-pharmacy area inspections with no distinguishable patterns and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that controlled substances inspectors consistently validate transfers from one storage area to another and that the Controlled Substances Coordinator monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that controlled substances inspectors consistently verify hard copy orders for five randomly selected dispensing activities (or a minimum of two if less than five dispensing activities on the unit) and that the Controlled Substances Coordinator monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that pharmacy employees consistently perform 72-hour inventories of the main vault and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that controlled substances inspectors consistently compare drugs held for destruction with the Destruction File Holding Report for 10 randomly selected drugs and that the Controlled Substances Coordinator monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that controlled substances inspectors consistently verify completion of drug destructions at least quarterly and that the Controlled Substances Coordinator monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that clinicians communicate incomplete or probably benign results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
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.
Review of Alleged Patient Scheduling Issues at the VA Medical Center in Tampa, FL
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15-03026-101

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended the Director of James A. Haley Veterans’ Hospital coordinate with the responsible contracting officer to develop a mechanism to ensure the facility receives prompt notification of scheduled Veterans Choice Program appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital request that the responsible contracting officer determine if Health Net complies with the modification to the Patient-Centered Community Care contract requiring the contractor to notify VA when a veteran is scheduled for an appointment through the Veterans Choice Program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services transmit all scheduling audit results to appropriate staff for awareness and corrective action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services develop a procedure to verify the schedulers properly correct identified errors.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital ensure supervisors provide additional training to schedulers regarding the management of the Veterans Choice List to ensure staff add all eligible veterans to the Veterans Choice List in a timely manner and that veterans remain on the Veterans Choice List.
Review of Alleged Untimely Care at VHA’s Community Based Outpatient Clinic Colorado Springs, CO
|
15-02472-46

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the clinically indicated or preferred appointment dates when scheduling primary care patient appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the earliest appropriate date when scheduling new patient appointments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended the Eastern Colorado Health Care System Director ensure that staff place all veterans with appointments occurring over 30 days after the clinically indicated or preferred appointment date on the Veterans Choice List within 1 day of scheduling the appointment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended the Eastern Colorado Health Care System Director ensure that resources are sufficient for scheduling staff to act on consults within 7 days and appointment requests for newly enrolled veterans within 1 day of the approved appointment request.
Inspection of VA Regional Office Little Rock, Arkansas
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15-04983-86

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/28/2016
We recommended the Little Rock VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas
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15-05149-88

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that providers sign home telehealth assessments and treatment plans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
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