Date Issued
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Report Number
14-05173-518
All Reports
Date Issued
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Report Number
15-01708-36
Date Issued
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Report Number
15-04694-80
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/20/2016
We recommended that the facility implement a consistent Ongoing Professional Practice Evaluation process.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the facility repair damaged furniture in patient care areas or remove it from service and repair damaged walls.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/8/2016
We recommended that the facility repair or replace damaged vinyl floor tiles and heavily soiled, torn, and frayed carpeting in patient care areas.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that facility managers ensure wheelchairs used by patients and visitors are clean and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/21/2016
We recommended that facility policy include the frequency of competency assessment requirements for employees who prepare compounded sterile products.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/21/2016
We recommended that pharmacy managers establish compounded sterile products competency assessment requirements for pharmacists.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended that pharmacy managers ensure pharmacy employees who prepare compounded sterile products complete all competency components annually and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the facility revise the compounded sterile products safety/competency assessment checklist to include all required elements.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/11/2017
We recommended that pharmacy managers ensure employees who prepare compounded sterile products don all required personal protective equipment in the ante area prior to entering the IV Prep Room and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/11/2017
We recommended that pharmacy managers ensure the IV Prep Room has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that facility managers ensure employees perform and document daily floor cleaning in the compounding area and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the facility follow up on computed tomography scanners that fail annual inspection by the medical physicist.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 2/23/2017
We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 2/23/2017
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. 17
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians not place flags in the electronic health records of moderate- and low-risk patients and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians include an assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Date Issued
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Report Number
15-04693-79
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
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
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that facility managers ensure patient care areas are clean, damaged furniture is repaired or removed from service, and stained ceiling tiles are replaced and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that the facility comply with local policy for labeling multi-dose vials with expiration dates after initial use and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that dental clinic managers ensure all dental clinic employees complete hazard communication training on chemical classification, labeling, and safety data sheets and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that facility managers ensure compounded hazardous medications are stored separately from other inventory and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/3/2016
We recommended that facility managers ensure the emergency eyewash station in the chemotherapy pharmacy has documented weekly testing and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that the facility revise its temporary bed locations policy to include upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that clinicians validate patients' and/or caregivers' understanding of the discharge instructions provided.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
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. 13
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that the facility complete the required reports regarding patients who attempt or complete suicide and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 10/3/2016
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.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended that the domiciliary teaching kitchen have a Class K fire extinguisher available.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 10/3/2016
We recommended that domiciliary program managers ensure residents secure medications in their rooms and monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 6/14/2016
We recommended that facility managers revise the medication management policy to include securing all medications kept in patient rooms.
Date Issued
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Report Number
14-04530-41
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/10/2017
We recommended that the Central Alabama Veterans Health Care System Director charter a systems redesign team to improve the timeliness of care delivery in the Emergency Department.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that the Central Alabama Veterans Health Care System Director revise the Emergency Department triage policy to include reassessment expectations for patients designated as Emergency Severity Index levels 2–5.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/10/2017
We recommended that the Central Alabama Veterans Health Care System Director ensure that adequate staffing is available in the Emergency Department to assure safe special observation to mental health patients.
Date Issued
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Report Number
15-02217-85
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the Director, VA Hudson Valley Health Care System consult with VA NY/NJ Healthcare Network leadership and Regional Counsel regarding the acceptability of shuttle bus drivers’ use of the Passenger Fitness Criteria card.
Date Issued
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Report Number
15-05151-81
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that managers develop and implement a policy that requires the Grove City VA Clinic staff to receive regular information on their responsibilities in emergency response operations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians document verbal informed consent for Home Telehealth services.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that the facility director ensure that the facility's written policy for the communication of laboratory results includes all required elements.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/11/2018
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/11/2018
We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Date Issued
|
Report Number
14-02465-47
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health improve cost estimation tools to ensure adequate Non-VA Care cost estimates are produced consistently.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/28/2016
We recommended that the Under Secretary for Health implement a mechanism to ensure that VA medical facilities perform ongoing reviews and adjust cost estimates for individual authorized services to better reflect actual costs.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health update Fee Basis Claims System software to ensure inpatient authorizations can be periodically adjusted when the scope of patient care is fully known.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health update Fee Basis Claims System software to allow the system to automatically deobligate unused funds when Non-VA Care staff indicate payments for the authorized services are complete.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/17/2016
We recommended that the Under Secretary for Health implement a mechanism to monitor how effectively VA medical facilities are estimating Non-VA Care obligations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 358,000,000.00
Date Issued
|
Report Number
15-05148-75
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that managers test the panic buttons regularly at the Victor J. Saracini VA Outpatient Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Victor J. Saracini VA Outpatient Clinic to the parent facility.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that managers provide feminine hygiene disposal bins in women’s public restrooms at the Victor J. Saracini VA Outpatient Clinic.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/2/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Date Issued
|
Report Number
15-05158-74
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that clinic staff at the Joliet VA Clinic position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas.
No. 2
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 3
to Veterans Health Administration (VHA)
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
Date Issued
|
Report Number
14-03981-54
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/12/2016
We recommended the Oakland VA Regional Office Director provide training to the Quality Review Team, Decision Review Officers and Rating Veterans Service Representatives on proper informal claims processing procedures for communications received from service organizations, attorneys, or agents.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/15/2016
We recommended the VA Regional Office Oakland Director conduct a complete review of the additional list of 690 claims that may be informal claims, take appropriate actions, and provide certification of completion of the review to the Office of Inspector General.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/23/2017
We recommended the VA Regional Office Oakland Director conduct another review of the remaining 1,248 informal claims and provide certification of completion of the review to the Office of Inspector General.
Date Issued
|
Report Number
14-04302-12
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2016
We recommended the Director of the New York VA Regional Office take actions, as appropriate, to ensure similar incidents involving expediting friends’ disability claims do not occur in the future.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2016
We recommended the Director of the New York VA Regional Office develop and implement a mechanism to ensure staff have a venue for reporting violations of ethical standards of conduct in the future, should any occur.
Date Issued
|
Report Number
14-05075-447
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/7/2016
We recommended that the Facility Director ensure patients are notified and re-assigned timely when their mental health providers leave the facility.
Date Issued
|
Report Number
14-04979-11
Date Issued
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Report Number
14-04816-72
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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.
Date Issued
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Report Number
15-00992-71
Date Issued
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Report Number
14-04152-370
Date Issued
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Report Number
15-00827-68
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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.
Date Issued
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Report Number
14-04810-05
Date Issued
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Report Number
14-04761-09