Date Issued
|
Report Number
14-02634-397
All Reports
Date Issued
|
Report Number
14-04547-401
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health take steps to prevent prescriptions from being dispensed to deceased veterans.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Kansas City VA Medical Center Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Kansas City VA Medical Center Director ensure that processes be strengthened so medication reconciliation is consistently completed and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
We recommended that the Kansas City VA Medical Center Director conduct peer reviews of this patient’s care, to include the evaluation and treatment of recurrent falls and the coordination of care.
No. 5
to Veterans Health Administration (VHA)
We recommended that the Harry S. Truman Memorial Veterans’ Hospital Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
Date Issued
|
Report Number
15-00601-376
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges granted to match their skills and training.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that the facility reduce credentialing and privileging folders to the two-part format.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that the Operating Room Committee include the Chief of Staff as a member and that committee minutes reflect review of National Surgical Office reports.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that Infection Control Committee meeting minutes consistently reflect discussion of all identified high-risk areas.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure all buildings designated for health care occupancy at the Lake City campus have fire drills conducted once per shift per quarter and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that facility managers ensure negative air pressure systems in the Gainesville campus surgical intensive care unit are functional and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure Gainesville campus locked mental health unit stationary panic alarm testing includes documentation of VA Police response time and ensure testing of portable panic alarms and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure designated employees complete competency assessment on the use of emergency evacuation devices and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that engineering managers ensure all Gainesville campus construction workers wear VA-issued identification badges and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that facility managers ensure that oral syringes are available for liquid medications in all units/areas at the Lake City and Gainesville campuses and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that employees screen inpatients to determine whether they want to have a discussion about advance directives and document the screening and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of a completed written test and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/15/2015
We recommended that the facility report provider specific emergency airway management data to the Operative and Invasive Procedures Committee.
Date Issued
|
Report Number
14-05078-393
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the Facility Director ensure that provider privileges reflect current practice.
Date Issued
|
Report Number
15-01721-382
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents who may be candidates for restorative nursing services, the interdisciplinary team documents the reason the resident is not receiving the services or other activities to promote functional status.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents receiving or supposed to receive restorative nursing services, the interdisciplinary team documents goals in their care plans.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/11/2017
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that nursing employees provide and document restorative nursing services in accordance with the care plan, and if they do not provide the services, they document the reason.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees complete required restorative summary notes and that the Associate Chief Nurse or designee monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents not progressing toward restorative goals, the interdisciplinary team reassesses the resident care plan and/or adjusts goals and interventions as necessary.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that Physical Medicine and Rehabilitation therapists discharging residents from therapy document hand-off communication with nursing employees to ensure interventions continue or are discontinued, as applicable.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility managers provide and document nursing employee training on range of motion and transfers.
Date Issued
|
Report Number
15-02276-391
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/5/2016
We recommended that the Interim Under Secretary for Health evaluate options that would allow managers to identify individuals who access non-sensitive patient electronic health records.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that Mental Health Assessment Team appointments are scheduled within required timeframes, that patients are properly notified of those appointments, and that appropriate follow-up is documented when patients miss Mental Health Assessment Team appointments.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that Housing and Urban Development-VA Supportive Housing program contacts or home visits occur as outlined in the patient's treatment plan.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that patient record flags identifying patients at risk for suicide are placed promptly and that required high-risk protocols, including weekly contacts, are implemented and documented accordingly.
Date Issued
|
Report Number
15-02456-396
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Under Secretary for Health review current acute stroke treatment policies, and assess the use of telehealth evaluation and more aggressive local treatment in patients presenting to rural and/or low complexity VHA facilities with signs and symptoms of an acute stroke.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Under Secretary for Health review processes to improve the ability to identify unauthorized access to VA medical records.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Under Secretary for Health evaluate the complex rules related to reimbursement for a veteran’s emergency care at non-VA facilities, and determine if changes in policy or law would make it more likely that veterans would make decisions on where to seek emergency care based upon medical circumstances, rather than fear of adverse financial impact.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that patients and their families are educated about the services the UCC is equipped to provide.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that employees who are involved in assessing and treating stroke patients receive the web-based acute ischemic stroke training required by the facility and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/4/2016
We recommended that the Facility Director ensure that transfer agreements are established as required.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director review and evaluate computerized tomography scanner routine maintenance schedules to determine if routine maintenance can be conducted during periods of traditionally low utilization.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure Urgent Care Clinic processes are strengthened to reduce door-to-triage timeliness.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that appropriate staff receive Emergency Department Integration Software training.
Date Issued
|
Report Number
15-01297-368
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians perform and document medication reconciliation at each outpatient episode of care when a new medication is prescribed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently provide and document patient education for new outpatient medications.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently assess and document outpatients' understanding of medication education.
Date Issued
|
Report Number
14-00730-206
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/1/2015
We recommended Deputy Assistant Secretary for Acquisition and Logistics take steps to consult with the Office of General Counsel to remedy the inappropriate expenditure of approximately $2.3 million of expired funds, determine whether VA should
de-obligate any outstanding balances, and evaluate the need to return Supply Fund service fees of approximately $5.6 million.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/1/2015
We recommended Deputy Assistant Secretary for Acquisition and Logistics implement a corrective action plan to ensure that fiscal controls are enforced to avoid future misuse of appropriated funds, including inappropriate use of the VA Supply Fund, and the parking of funds.
No. 3
to Office of Management (OM)
Closure Date: 2/18/2016
We recommended the Deputy Assistant Secretary for Finance review the fiscal controls in the Financial Management System to ensure data integrity and an audit trail that reflects the occurrence and source of any accounting record changes.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended the Deputy Under Secretary for Health for Operations and Management confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any, against
Chief Business Office officials for directing the misuse of approximately $43.1 million of fiscal year 2011 appropriated funds.
No. 5
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/1/2015
We recommended the Deputy Assistant Secretary for Acquisition, Logistics, and Construction confer with the Office of Human Resources and the VA Office of General Counsel to determine the appropriate administrative action to take, if any, against Supply Fund management for circumventing controls over the management of funds.
Date Issued
|
Report Number
14-05158-377
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/18/2015
We recommended the Facility Director remove the language in the Computerized Patient Record System outpatient psychological testing consult that may be interpreted as instructing providers not to enter a consult.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended the Facility Director reevaluate and make the appropriate changes to the methods for referring patients for mental health care, including the extent to which the consult package is being used appropriately.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended the Facility Director ensure that mental health consults are reviewed and closed in accordance with Veterans Health Administration policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended the Facility Director ensure that Veterans Health Administration appointment scheduling guidance is followed and that schedulers utilize the electronic waiting list and give priority to service connected veterans, as appropriate.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended the Facility Director review all existing mental health wait lists to identify patients who may be at risk because of a delay in the delivery of mental health care and provide the appropriate care.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended the Facility Director expand access to mental health services, particularly required evidence-based psychotherapy and intensive case management services.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended the Facility Director ensure that mental health staff is available in the Emergency Department as required by Veteran Health Administration and local policy to avoid potential delays in admission to the inpatient psychiatry unit.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended the Facility Director review guidance provided to staff about meeting performance measures and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
Date Issued
|
Report Number
14-04573-378
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director evaluate the care of the cases discussed in this report with Regional Counsel for possible disclosure(s) to the patient(s) and/or surviving family members.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director require the Facility Director to conduct peer reviews of the cases identified in this report and take appropriate action to evaluate clinical competence of the providers involved in these cases based on the results of those reviews and this report.
No. 3
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director send a team to evaluate the facility’s Dental Service and oversee the implementation of any recommendations for improvement in scheduling and the general provision of dental care at the facility made by that team.
No. 4
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director provide appropriate and timely neurosurgical consultation services to patients receiving care at the facility consistent with Veterans Health Administration Directive 2008-056, VHA Consult Policy, September 16, 2008.
No. 5
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that all documents that patients and non-VA providers receive regarding maternity/obstetric care and services are reviewed and revised to eliminate ambiguous language.
No. 6
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that providers document all clinically pertinent telephone conversations concerning patient care.
No. 7
to Veterans Health Administration (VHA)
We recommended that Veterans Integrated Service Network and the Facility Director ensure adequate parking space requirements to strengthen a safe work environment, patient satisfaction, and provide optimal safety to patients, visitors, and staff.
No. 8
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network and the Facility Director ensure that Ernest Childers VA Outpatient Clinic access and parking is adequate and safe for patients, visitors, and employees.
Date Issued
|
Report Number
15-00359-374
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians adjust fluoroquinolone doses and/or frequencies consistent with manufacturers' recommendations when patients' estimated glomerular filtration rate values are below targeted thresholds.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians providing medication education document the accommodations made to address patients¿ identified learning barriers.
Date Issued
|
Report Number
15-02354-220
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear or cancel controls for claims.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director implement a plan to routinely monitor system controls for pending claims, to prevent further manipulation attempts and ensure staff do not prematurely change or remove controls.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director submit the 13 remaining and previously unavailable claims the employee cancelled in FY 2013 to OIG for review.
Date Issued
|
Report Number
15-00425-380
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the System Director ensure that processes be developed to improve storage conditions of compounded sterile products on applicable patient units in an effort to reduce unnecessary waste.
Date Issued
|
Report Number
14-02195-381
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that the Facility Director ensure that Radiology Department managers confirm that ordered magnetic resonance imaging exams are scheduled and completed within the Veterans Health Administration required timeframe.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that the Facility Director require Radiology Department managers to review pending lists of magnetic resonance imaging exams at designated intervals to ensure timely scheduling of these exams and that compliance be monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that the Facility Director ensure Radiology Department managers develop and implement a consistent procedure for canceling magnetic resonance imaging orders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the Facility Director ensure that responsible providers are notified of canceled magnetic resonance imaging orders.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 10/20/2015
We recommended that the Facility Director ensure that radiology clerical staff accurately annotate reasons for canceling magnetic resonance imaging orders and appointments in the electronic health record.
Date Issued
|
Report Number
15-00143-372
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
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
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coach training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians consistently notify patients of their laboratory results within 14 days, per local and VHA policy.
Date Issued
|
Report Number
15-00131-373
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that signage is installed at the Marietta CBOC to clearly identify the location of fire extinguishers obscured from view.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that the information technology server closet at the Marietta CBOC is maintained according to information technology safety and security standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Clinic Registered Nurse Managers receive motivational interviewing and health coaching training within the time frame specified by VHA policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that providers in the outpatient clinics receive health coaching training within the timeframe specified by VHA policy.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that clinicians consistently notify patients of their lab results within 14 days as required by VHA.
Date Issued
|
Report Number
15-02627-386
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommended that the Interim Under Secretary for Health determine the feasibility and advisability of expanding recovery coordination activities to patients with post-traumatic stress disorder.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that the Veterans Integrated Service Network Director ensure that the VA Central Iowa Health Care System Director provides all levels of Operation Enduring Freedom/Operation Iraqi Freedom case management services in accordance with Veterans Health Administration policy.
Date Issued
|
Report Number
15-00125-367
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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. 4
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Date Issued
|
Report Number
15-00127-357
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that panic alarms are tested and testing is documented at the Reno East Campus CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.