All Reports

Review of Alleged Problems With VBA’s Veterans Benefits Management System and Claims Processing
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14-04816-72

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/8/2016
We recommended the Under Secretary for Benefits ensure that the St. Petersburg VA Regional Office is consistently organizing and mailing hard copy veteran material to contractor scanning facilities and hold the Regional Office Director accountable for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/9/2016
We recommended the Under Secretary for Benefits initiate onsite reviews of the CACI contractor scanning facilities to ensure the timely processing and the proper storage of VA sensitive information at those facilities.
Healthcare Inspection – Poor Follow-Up Care and Incomplete Assessment of Disability, VA San Diego Healthcare System San Diego, California
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15-00827-68

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the Under Secretary for Health ensure that Compensation & Pension examiners document that patients with new diagnoses are counseled on the need for follow up care and provided assistance in obtaining VA care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Under Secretary for Health develop guidance on what clinical information from secure messaging and My HealtheVet must be documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the System Director implement processes to ensure that providers adhere to the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, including follow up assessment at appropriate intervals, when treating patients with chronic opioid therapy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the System Director confer with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2016
We recommended that the VA Regional Office San Diego Director review a sample of the specific rater’s work and determine whether failure to obtain relevant service treatment records is a systemic issue with this rater when making compensation claim decisions.
Healthcare Inspection – Eye Care Concerns, Eastern Kansas Health Care System, Topeka and Leavenworth, Kansas
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15-00268-66

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director ensure all system staff use only approved wait lists for scheduling cataract surgeries as required by Veterans Health Administration Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, June 2010.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director ensure that providers use the consultation package in the Computerized Patient Records System for all eye care referrals as required by VHA Handbook 1121.01, VHA Eye Care, March 10, 2011.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director take actions to increase ophthalmologists’ productivity.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director explore and implement measures to improve communication, interpersonal dynamics, and operations within and between both Eye Clinics.
Combined Assessment Program Review of the Royal C. Johnson Veterans Memorial Medical Center, Sioux Falls, South Dakota
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15-04699-65

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Louis A. Johnson VA Medical Center, Clarksburg, West Virginia
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15-00178-56

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that staff protect patient-identifiable information on laboratory specimens at the Monongalia County VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that the information technology server closet at the Monongalia County VA Clinic is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
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15-00614-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that credentialing and privileging folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas are clean and bathrooms are free from offensive odors and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers initiate corrective actions to repair the ceiling leak in the operating room supply area.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
We recommended that the facility annually review the look-alike and sound-alike medication list.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a written policy for the safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that consultants consistently link consult responses to the requests and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
Inspection of VA Regional Office Hartford, CT
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15-04986-42

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2015
We recommended the Hartford VA Regional Office Director conduct a review of the three temporary 100 percent disability evaluations remaining from our inspection universe as of August 11, 2015, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2016
We recommended the Hartford 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 Salem VA Medical Center, Salem, Virginia
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15-00181-53

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2016
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Charles George VA Medical Center, Asheville, North Carolina
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15-00175-50

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that the Facility Director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Review of Alleged Beneficiary Travel Irregularities at Hudson Valley HCS, Hampton & Lexington VAMCs
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15-02400-524

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System complies with VHA Procedure Guide requirements to use the Beneficiary Travel Dashboard to calculate mileage as the basis for reimbursement.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System’s and the Hampton Veterans Affairs Medical Center’s Beneficiary Travel Dashboards are configured to assist staff in identifying the nearest facility able to provide care or services as the basis for mileage reimbursements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers strengthen Beneficiary Travel Program processing accuracy by developing a formal plan to routinely identify staff training needs and provide appropriate training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers develop and implement a formal process to routinely identify Beneficiary Travel Program mileage reimbursement processing deficiencies and apply corrective actions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health requires the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers to determine whether the improper payments identified by our review warrant establishing bills of collection or reimbursing beneficiaries, when applicable.
Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia
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15-00628-49

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Critical Care Committee continue the recently implemented process that includes screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that damaged wheelchairs are repaired or removed from service and that wheelchairs are included in the facility’s preventative maintenance program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that employees follow facility policy for disinfection of non-critical equipment between patients and that exam rooms contain adequate supplies for disinfection.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient-specific insulin vials distributed to units are consistently labeled with correct expiration dates and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that surgical intensive care unit nurses have 12-lead electrocardiogram and post-anesthesia care competency assessment and validation included in their competency checklists.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that initial clinician emergency airway management competency assessment includes all required subject matter content elements and evidence of a completed written test and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Combined Assessment Program Summary Report – Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities
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15-03804-38

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently conduct initial magnetic resonance imaging patient safety screenings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel consistently document when they review the second magnetic resonance imaging patient safety screening forms.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel document resolution of all identified potential contraindications prior to the magnetic resonance imaging exam.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities routinely conduct contrast reaction drills in magnetic resonance imaging areas.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that all designated Level 1 ancillary employees receive annual level-specific magnetic resonance imaging safety training.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
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15-00157-39

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Stillwater VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that signage is installed at the Stillwater VA Clinic to clearly identify the location of the fire extinguisher in the lobby area.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinic staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Stillwater VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
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