Date Issued
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Report Number
14-04310-280
All Reports
Date Issued
|
Report Number
14-02890-291
Date Issued
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Report Number
14-02890-286
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
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
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.
Date Issued
|
Report Number
16-00108-274
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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.
Date Issued
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Report Number
15-03802-222
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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.
Date Issued
|
Report Number
11-00826-261
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
Date Issued
|
Report Number
15-03581-204
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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.
Date Issued
|
Report Number
14-02890-292
Date Issued
|
Report Number
15-05154-271
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 7
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
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
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
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
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
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Date Issued
|
Report Number
16-00112-267
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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.
Date Issued
|
Report Number
16-00693-269
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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.
Date Issued
|
Report Number
16-00017-245
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 3
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
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.
Date Issued
|
Report Number
15-02384-212
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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.
Date Issued
|
Report Number
16-00115-263
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
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
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that facility managers ensure Peer Review Committee monthly meetings are documented.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
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 facility and the community based outpatient clinics.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that facility managers ensure operating room housekeepers complete initial training on cleaning and disinfection procedures.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/12/2016
We recommended that the facility develop a policy that addresses temporary bed locations.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/12/2016
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. 8
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently identify and document deficiencies concerning resident privacy, submit work orders for items needing repair, and document corrective actions taken for identified deficiencies and that program managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband, 2-hour rounds of all public spaces, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that the unit 10-B and unit 8-B main points of entry have keyless entry systems.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 4/19/2016
We recommended that facility managers ensure that the closed circuit television system on unit 8-B have recording capabilities and that unit 10-B have signage alerting veterans and visitors of closed circuit television recording.
Date Issued
|
Report Number
16-00012-251
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/17/2016
We recommended that employees at the Statesboro VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/17/2016
We recommended that managers ensure that Statesboro VA Clinic staff participate in emergency management training and exercises.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that the clinic manager ensures that Statesboro VA Clinic employees receive the required hazardous communications training.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens.
Date Issued
|
Report Number
16-00023-252
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that clinicians document assessments and treatment plans for Home Telehealth patients.
No. 2
to Veterans Health Administration (VHA)
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 4
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe required by VHA.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/19/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Date Issued
|
Report Number
16-00019-249
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the clinic manager reviews the Greeley VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/7/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/7/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Date Issued
|
Report Number
16-00013-242
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/20/2016
We recommended that the Facility Director ensures that signs identify the location of fire extinguishers that are in large rooms or are obscured from view at the Cameron VA Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the clinic manager reviews the Cameron VA Clinic's hazardous materials inventory twice within a 12-month period.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that the Cameron VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that clinic staff protect patient-identifiable information on laboratory specimens during transport.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/21/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/20/2016
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Date Issued
|
Report Number
15-04652-146
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/14/2019
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to ensure documents printed from Veterans Benefits Management System are clearly identified.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to include detailed, standardized procedures for the collection and review of material by records management staff at VA Regional Offices.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure all claims-related documents receive the mandated levels of review to comply with Veterans Benefits Administration’s policy.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/15/2017
We recommended the Acting Under Secretary for Benefits implement a plan that requires supervisors to conduct periodic reviews of employees’ red boxes and track all shredding policy violations they identify.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure records management staff comply with Veterans Benefits Administration’s policy to track all shredding violations they identify.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits implement a plan to ensure management and staff receive refresher training on the proper handling of both claims-related and non-claims-related documents.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits develop specific procedures regarding the maintenance and disposition of congressional correspondence.
Date Issued
|
Report Number
15-04652-266
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2016
We recommended the VA Regional Office Director implement a plan to ensure the Los Angeles VA Regional Office staff comply with the Veterans Benefits Administration’s policy for handling, processing, and protection of claims-related documents.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2016
We recommended the VA Regional Office Director assess the effectiveness of the training provided to the Los Angeles VA Regional Office staff on Veterans Benefits Administration’s policy for managing veterans’ and other governmental records.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/24/2016
We recommended the VA Regional Office Director provide documentation to VA OIG that proper action has been taken to process the eight cases that had the potential to affect veterans’ benefits.