All Reports

Review of Alleged Mismanagement at the Health Eligibility Center
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14-01792-510

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended the Under Secretary for Health provide guidance concerning how long applications may remain pending before reaching a final determination.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health assign an accountable official responsible to implement a plan to correct current data integrity issues in the Enrollment System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended the Under Secretary for Health develop and execute a project management plan to ensure that Enrollment System data are fully evaluated and properly categorized.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health implement controls to ensure that future enrollment data are accurate and reliable before being entered in the Enrollment System.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health implement effective policies and procedures to accurately and timely identify deceased individuals with records in the Enrollment System and record their changed status in the system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended the Under Secretary for Health establish appropriate policies and procedures to ensure Health Eligibility Center workload data are not deleted or changed without appropriate management review, approval, and audit trails.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to Health Eligibility Center workload data are based upon specific job duties and the need to know.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the first three allegations, determine if administrative action should be taken against any senior Veterans Health Administration officials involved, and ensure that appropriate action is taken.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/22/2016
We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/21/2016
We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/21/2016
We recommended that the Assistant Secretary for Information and Technology develop a monthly schedule to test whether Health Eligibility Center workload data are backed up properly and to provide the results of such testing to the Chief Business Office.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/29/2016
We recommended the Assistant Secretary for Information and Technology confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the lack of controls over the Workload Reporting and Productivity tool, determine if administrative action should be taken against any senior Office of Information Technology officials involved, and ensure that appropriate action is taken.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health perform monthly comparisons between Workload Reporting and Productivity reports and enrollment records to ensure the timely processing of applications and related documents.
Healthcare Inspection – Alleged Delayed Mental Health Treatment and Other Care Issues, Kansas City VA Medical Center, Kansas City, MO
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14-03531-402

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that the Interim Under Secretary for Health review relevant inpatient program occupancy rates and wait times system-wide and determine whether additional guidance to facilities is needed to help ensure that the number of patients served through those programs is optimized.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2016
We recommended that the Facility Director ensure that processes be strengthened to ensure appropriate follow through on consults that are cancelled for administrative reasons.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2016
We recommended that the Facility Director ensure that Emergency Department providers fully evaluate patients with abnormal findings and make those evaluations readily accessible to other providers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2016
We recommended that the Facility Director ensure that patients are evaluated and referred for treatment for certain health concerns if exhibited by patients presenting to the Emergency Department, when appropriate.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Maine Healthcare System, Augusta, Maine
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15-00154-500

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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 clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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: 2/17/2017
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching 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: 4/20/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2016
We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/11/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages
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15-03063-511
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration further develops staffing models for critical need occupations.
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 review the data on regrettable losses in this report and Veterans Integrated Service Network Workforce Succession Strategic Plans and, if appropriate, consider implementing measures to reduce such losses.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Durham VA Medical Center, Durham, North Carolina
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15-00158-499

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that review of the hazardous materials inventory occurs twice within a 12-month period at the Raleigh II CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Raleigh II CBOC participate in scheduled emergency management training and exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
Review of VHA’s Alleged Mishandling of Ophthalmology Consults at the Oklahoma City VAMC
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15-02397-494

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure patients affected by inappropriately discontinued ophthalmology consults receive the necessary eye care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center initiate a review of discontinued teleretinal imaging consults and take action to provide eye care when necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that guidance and responsibilities for making referrals on discontinued and cancelled consults is well-defined and formalized into policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that staff responsible for initiating and processing consults are properly trained on all applicable guidance and policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that all referring providers with electronic notifications responsibility receive adequate training.
Combined Assessment Program Review of the Battle Creek VA Medical Center, Battle Creek, Michigan
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15-00606-495

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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 monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers maintain auditory privacy in all intake/exam areas and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
No. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers revise the Radiology Service computed tomography quality assurance guideline to include radiologist review of appropriateness of computed tomography orders and specification of protocol prior to scans.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that facility managers comply with Veterans Health Administration directive requirements for exempted facilities, or if facility managers plan emergency intubation responses with onsite employees, they comply with Veterans Health Administration requirements for non-exempted facilities.
Inspection of VA Regional Office Phoenix, Arizona
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15-01381-437

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/17/2015
We recommended the Phoenix VA Regional Office Director conduct a review of the 325 temporary 100 percent disability evaluations remaining from their inspection universe as of December 17, 2014, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2016
We recommended the Phoenix VA Regional Office Director ensure frequent refresher training for processing higher levels of special monthly compensation and ancillary benefits claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2016
We recommended the Phoenix VA Regional Office Director implement a written plan to ensure oversight and prioritization of benefits reduction cases and related hearings.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of San Francisco VA Health Care System, San Francisco, California
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15-00156-490

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
We recommended that hand hygiene compliance is monitored at the San Francisco VA Clinic and reported to the Infection Control Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended that San Francisco VA Clinic staff store medical waste in a secure location.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended that clinic staff ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2016
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2016
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: 8/22/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Audit of Fiduciary Program Controls Addressing Beneficiary Fund Misuse
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13-03922-453

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2015
We recommended the Under Secretary for Benefits revise policy to require timely removal of a fiduciary from all assigned beneficiaries when an individual case of misuse has been determined.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2017
We recommended the Under Secretary for Benefits retroactively establish debts for all fiduciaries who VBA determined misused beneficiary funds during calendar year 2013.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2015
We recommended the Under Secretary for Benefits revise policy to include clear timeliness standards from the time the hubs determine misuse occurred to the time Pension and Fiduciary Service completes the negligence determination.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2017
We recommended the Under Secretary for Benefits ensure the processing of all misuse actions are incorporated into quality reviews of Fiduciary Program operations.
Inspection of VA Regional Office, Winston-Salem, North Carolina
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15-00452-411

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/28/2015
We recommended the Winston-Salem VA Regional Office Director conduct a review of the 597 temporary 100 percent disability evaluations remaining from our universe as of October 8, 2014, and take appropriate actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/28/2015
We recommended the Winston-Salem VA Regional Office Director develop and implement a plan to ensure claims processing staff receive additional training on required actions relating to required medical reexaminations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/28/2015
We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff receive refresher training on processing higher-level special monthly compensation claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/4/2016
We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Inspection of VA Regional Office Wichita, Kansas
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15-01290-435

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/19/2016
We recommended the Wichita VA Regional Office Director conduct a review of the 130 temporary 100 percent disability evaluations remaining from our inspection universe as of December 10, 2014, and take appropriate actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/19/2016
We recommended the Wichita VA Regional Office Director implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/19/2016
We recommended the Wichita VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Combined Assessment Program Review of the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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15-00604-488

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2016
We recommended that the facility document evacuation sled training in the Talent Management System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2016
We recommended that facility managers ensure post-anesthesia care competency assessment is completed for critical care nurses on the intensive care units.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes review of clinician-specific data and all required elements and that facility managers monitor compliance.
Audit of VHA’s Efforts To Improve Veterans’ Access to Outpatient Psychiatrists
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13-03917-487

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended the Under Secretary for Health ensure Veteran Integrated Service Networks and facilities incorporate the Office of Mental Health Operations staffing model to determine the appropriate number of psychiatrists needed for outpatient care, and work with those facilities to attain appropriate staffing levels or identify alternative options to meet veteran demand for psychiatrists.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended the Under Secretary for Health develop clinic management business rules to ensure facilities consistently monitor the use of clinical time and number of veterans per psychiatrist, in conjunction with monitoring psychiatrists’ productivity.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended the Under Secretary for Health reassess the appropriateness of the Veterans Health Administration’s productivity target for psychiatrists.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 567,000,000.00
Inspection of VA Regional Office St. Petersburg, Florida
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15-00001-436

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended the St. Petersburg VA Regional Office Director conduct a review of the 1,717 temporary 100 percent disability evaluations remaining from our inspection universe as of October 8, 2014, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2016
We recommended the Under Secretary for Benefits direct Veterans Benefits Administration field offices prioritize processing reminder notifications within 30 days as required.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/18/2016
We recommended the St. Petersburg VA Regional Office Director implement a plan to improve the effectiveness of the second-signature review process for special monthly compensation and ancillary benefits rating decisions
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/18/2016
We recommended the St. Petersburg VA Regional Office Director implement a plan to provide training and assess the effectiveness of that training, to ensure staff establish accurate dates of claim in the electronic systems.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2016
We recommended the St. Petersburg VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reductions cases.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2016
We recommended the Under Secretary for Benefits direct Veterans Benefits Administration field offices to prioritize benefits reductions cases in order to minimize overpayments.
Combined Assessment Program Review of the San Francisco VA Health Care System, San Francisco, California
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15-00607-483

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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 facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2016
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)
Closure Date: 8/3/2016
We recommended that Environment of Care Committee meeting minutes track open items to resolution.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that Infection Control Committee meeting minutes reflect discussion of all identified high-risk areas and implementation of actions to address those areas.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2016
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that facility managers ensure personal protective equipment gowns and eyewear are readily available in all patient care areas and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2016
We recommended that employees promptly remove outdated commercial supplies from sterile supply rooms and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2016
We recommended that the facility consistently implement corrective actions for issues identified during monthly community living center medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that facility managers ensure that parenteral syringes are not used to measure oral liquid medications and monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2016
We recommended that computed tomography technologists perform and document quality assurance checks each weekday and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions using the required advance directive note titles and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that facility managers ensure that only sharps are disposed of in sharps containers and monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
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15-00152-481

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2016
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and 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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2016
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: 3/30/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2016
We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York
|
15-00597-462

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassesses observation criteria and utilization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that the CPR Committee review each code episode.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that the Surgical Work Group document its review of National Surgical Office reports.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility keep the recipient list for the automated Critical Incident Tracking Notification e-mail current.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended that the facility review the quality of entries in the electronic health record at least quarterly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that the quality control policy for scanning include a complete review of scanned documents to ensure readability and retrievability and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that the facility revise the observation bed policy to reflect Veterans Health Administration policy and current practice.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that the Infection Control Committee consistently document analysis of surveillance activities and data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that facility managers delegate responsibility for cleaning non-critical equipment and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility establish a policy/procedure/guideline for the identification of individuals entering the facility and that facility manager's monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that facility managers ensure that furniture in inpatient mental health patient care areas is compliant with the VA National Center for Patient Safety Mental Health Environment of Care Checklist and monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that the facility maintain ventilation, temperature, and humidity levels in inpatient care areas according to Joint Commission and Centers for Disease Control and Prevention guidelines and VA policy to provide a safe environment for patients, staff, and visitors and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility establish a list of resources and assets it may need during an emergency.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility¿s Emergency Operations Plan include the management of a potential increase in demand for clinical services for patients who are geriatric or disabled or have serious chronic conditions or addictions and the management of mental health services during an emergency.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that the facility develop and implement a process for managing and labeling high-alert medications and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility develop policies and procedures for managing and reviewing revised computed tomography protocols.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2016
We recommended that a medical physicist review all revised computed tomography protocols and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that radiologists ensure all computed tomography reports contain the radiation dose and that facility managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees submit timely work orders for items needing repair and that program managers ensure deficiency correction.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees perform and document contraband inspections and that program managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
We recommended that Substance Abuse Residential Rehabilitation Treatment Program managers ensure that the program has written agreements in place acknowledging resident responsibility for medication security.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program managers ensure that closed circuit television does not monitor treatment activities.
Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
|
15-00603-477

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the Surgical Work Group meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that the facility include most outpatient services in the review of electronic health record quality.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2016
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2016
We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for all users with access to the machines.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that teleradiology include radiation dose information in computed tomography summary reports and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening using the appropriate note titles and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions using the required advance directive note titles and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2015
We recommended that the facility develop and grant a scope of practice that includes emergency airway management for respiratory therapists who have established competency to perform the procedure.
Administrative Investigation, Improper Use of Web-based Collaboration Technology, Office of Information and Technology
|
13-03054-463

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2016
We recommend that the VA Chief of Staff confer with the Offices OIT, OPIA, and General Counsel (OGC) to ensure that VA Yammer is formally evaluated, approved, and/or disapproved for VA use. If approved, ensure it meets all Federal laws and regulations, as well as VA policy and guidance. If disapproved, ensure that all VA employees cannot access it from VA-issued equipment or VA's network.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommend that the VA Chief of Staff confer with the Offices of Human Resources (OHR), Accountability Review (OAR), and OGC to determine the appropriate administrative action to take, if any, against accountable OIT and OPIA officials, as well as other VA and contractor employees involved in this particular matter.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommend that the VA Chief of Staff ensure that all VA employees are made fully aware of which Web-based collaboration technologies VA has approved for their use and which are prohibited.
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