All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of John J. Pershing VA Medical Center, Poplar Bluff, Missouri
|
15-00142-35

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Pocahontas VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that safety data sheets are current at the Pocahontas VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Pocahontas VA Clinic is maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
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. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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 provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that practitioners document a relevant history of the illness or injury and physical findings when the patients are first admitted for VA outpatient care.
No. 10
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 VHA.
Healthcare Inspection – Access and Oversight Concerns for Home Health Services, Washington DC VA Medical Center, Washington, District of Columbia
|
14-03823-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended that the Under Secretary for Health require facilities to developaction plans to address the care needs of patients on home health services electronic wait lists.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility Director ensure that staff comply with all elementsof national and local policies regarding quality of care, communication, and documentation related to purchased home and community based services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that the Facility Director ensure that oversight and managementof purchased home and community based services is adequate and in compliance with Veterans Health Administration policies.
Audit of the Seismic Safety of VA’s Facilities
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14-04756-32

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/2/2017
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction establish policy requiring medical facilities to conduct detailed seismic studies for all critical and essential buildings located in high and very high seismic zones that have not already undergone detailed seismic studies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to require Facility Condition Assessment contractors to review structural design documents for buildings that have completed seismic retrofit projects.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to ensure conditions of seismically unsafe buildings are properly reported on assessment reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
We recommended the Under Secretary for Health ensure medical facilities submit construction project applications, in a timely manner, for all identified seismically unsafe structural and nonstructural deficiencies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure that Facility Condition Assessment contractors include specific and detailed descriptions of nonstructural seismic deficiencies in their assessments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended the Under Secretary for Health ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/2/2017
We recommended the Acting Assistant Secretary for Management revise VA Directive 7415 to mandate that enhanced use lease agreements require developers to certify the seismic safety of buildings or to have a plan for mitigating identified seismic deficiencies prior to renewal or execution of new facility use agreements with VA organizations.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
We recommended the Under Secretary for Health develop policies and procedures requiring VHA medical facilities to develop and test Continuity of Operations Plans, to include documenting the testing performed, in accordance with Federal Continuity Directive 1 requirements.
Combined Assessment Program Review of the Charles George VA Medical Center,Asheville, North Carolina
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15-00621-23

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2015
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: 3/29/2016
We recommended that the Surgical Work Group meet monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility include most services in the review of electronic health record quality.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure negative air pressure systems on the surgical intensive care unit are functional and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure that locked mental health unit stationary and portable panic alarm testing includes documentation of VA Police response times.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the corrective actions until fully resolved.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for nursing employee users and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility revise the local policy to include that all designated non-anesthesia providers receive training in emergency airway management.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility complete a root cause analysis for the event to determine why this vulnerability existed and initiate appropriate system improvements.
Combined Assessment Program Review of the VA Pacific Islands Health Care System, Honolulu, Hawaii
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15-00626-28

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
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: 6/16/2016
We recommended that Environment of Care Committee meeting minutes consistently document tracking of identified deficiencies to closure and that monthly meetings consistently include community based outpatient clinic representation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that Infection Control Committee meeting minutes consistently reflect discussion of identified high-risk areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that facility managers ensure furnishings and equipment in patient care areas are in good repair and have upholstery that is easily cleaned.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure employees routinely inspect Center for Aging privacy and shower curtains and initiate actions to replace those with stains.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure heavy-use public restrooms in the ambulatory care center have frequent inspections and receive cleaning as needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers initiate corrective actions to repair the ceiling leak in the ambulatory care center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that employees store clean and dirty items separately and promptly remove cardboard boxes from storage areas and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended that facility managers ensure negative air pressure systems are functional in all designated rooms and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure all chairs in the acute psychiatry unit 3B2 dining/activity room are weighted.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility’s Emergency Operations Plan include all required Joint Commission elements.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility implement an adequate back-up plan for a Suicide Prevention Coordinator.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and for identifying and tracking patients who are at high risk for suicide
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility implement a process to follow up on patients who miss MH appointments and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that clinicians include patients and/or their families in safety plan development and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that mental health providers ensure outpatients flagged as high risk for suicide have a suicide prevention safety plan completed within the first 72 hours of contact and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that mental health providers ensure outpatients flagged as high risk for suicide are evaluated at least four times within 30 days of flag placement if an outpatient or at least four times within 30 days of discharge from the inpatient psychiatric unit and that facility managers monitor compliance.
Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri
|
15-00600-33

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
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: 8/9/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the privileges to do so.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers ensure emergency airway management privileges for licensed independent practitioners are reviewed, signed, and dated prior to granting the privileges.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the Cardiopulmonary Resuscitation Committee review all episodes of care where resuscitation was attempted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility ensure the recently established Safe Patient Handling Committee continues to meet and provide oversight of the safe patient handling program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers ensure all sharps containers are sealed tightly at the point of collection and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that facility managers ensure evacuation devices are immediately accessible in patient care areas and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that for all construction projects, the facility initiate Interim Life Safety Measures as required and post any needed alternative exit signage and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility revise the computed tomography policy to include a quality control program.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility revise the emergency airway management policy to include a plan to manage a difficult airway.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers strengthen processes to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and in instances of occurrence, initiate root cause analyses.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility ensure all home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order and that facility managers monitor compliance.
Healthcare Inspection – Alleged Program Inefficiencies and Delayed Care, Veterans Health Administration’s National Transplant Program
|
15-00187-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Under Secretary for Health review the extent of delays in responses to referrals for transplant evaluations; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely responses to referrals for liver transplant evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Under Secretary for Health review the extent of delays in initial patient evaluations for transplantation; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely initial patient evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended that, after reviewing the circumstances of delays in responses to referrals and initial patient evaluations for transplantation, the Under Secretary for Health take action to confirm that any patients who experienced delayed care that presented risks received appropriate care.
Combined Assessment Program Review of the Alaska VA Healthcare System, Anchorage, Alaska
|
15-00618-02

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director and other key members required by local policy attend Quality Committee meetings or have a delegate represent them.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility analyze electronic health record quality data at least quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Chief of Staff complete an audit of all licensed independent practitioners’ privileges to ensure they are current and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the health care occupancy building has at least one fire drill during administrative hours per quarter and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the tuberculosis prevention plan policy to reflect current status of negative air exchange rooms in the primary care clinic and ensure employees are aware of procedures to care for infectious patients in lieu of negative air exchange rooms.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure correction of all deficiencies identified during annual physical security surveys.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently complete a physical count of all primary care clinics during the 1st month of each quarter and a physical count of 10 line items for all primary care clinics during the 2nd and 3rd months of each quarter and that the Controlled Substances Coordinator monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently complete pharmacy inspections on the same day initiated and that the Controlled Substances Coordinator monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians communicate incomplete or “probably benign” results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure all patients assessed to be at high risk for suicide have documented safety plans that specifically address suicidality and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure that patients and/or their families receive a copy of the safety plan and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team and a centralized disruptive behavior reporting and tracking system.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that monthly self-inspection documentation includes safety, security, and privacy.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Risk Manager continue the recently implemented peer review corrective action tracking process and ensure actions are completed and reported to the Peer Review Committee.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers consistently initiate Focused Professional Practice Evaluations for newly hired licensed independent practitioners at the time or before they begin providing patient care.
Combined Assessment Program Review of the Marion VA Medical Center, Marion, Illinois
|
15-00623-18

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
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: 5/4/2016
We recommended that the interdisciplinary committee include a physician to review all episodes of care where resuscitation was attempted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility develop a computed tomography policy that includes all required elements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2016
We recommended that a medical physicist inspect computed tomography scanners that have repairs or modifications that affect dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility revise the electrocardiogram, blood bank, respiratory therapy, and radiology policies to clearly define appropriate availability for support services.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure Emergency Department and inpatient medical/surgical unit employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and completed and documented.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the intensive care unit.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2016
We recommended that facility managers implement a defined plan or policy to have a qualified surgeon available 24/7 on call within 60 minutes.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2016
We recommended that the facility revise the emergency airway management policy to include a plan to manage a difficult airway.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes completion of all required elements at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2016
We recommended that the facility ensure that a qualified, non-Emergency Department clinician is assigned inpatient emergency airway management coverage and that facility managers monitor compliance.
Healthcare Inspection – Poor Access to Care Allegedly Resulting in a Patient Death at the Oxnard Community Based Outpatient Clinic, VA Greater Los Angeles Healthcare System, Los Angeles, California
|
14-02890-497

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2016
We recommended that the Veterans Integrated Service Network Director ensure that the system provides neurology consults within timeframes required by patients' clinical conditions and current Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2016
We recommended that the System Director monitor provider compliance with timeframes for acting on and closing consults in accordance with the current Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2016
We recommended that the System Director ensure that providers categorize consults based on urgency and that program managers verify the accuracy of categorizations.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Battle Creek VA Medical Center, Battle Creek, Michigan
|
15-00155-16

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that staff protect and secure specimens and patient-identifiable information at the Muskegon VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Muskegon VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Muskegon VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2016
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2016
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA New Jersey Health Care System, East Orange, New Jersey
|
15-00163-01

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that managers ensure a safe, clean, and well maintained environment of care at the Morristown VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Morristown VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that all employees at the Morristown VA Clinic receive the required training on hazardous materials.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that managers ensure that all safety inspections on medical equipment are performed as required by facility policy at the Morristown VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Morristown VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that staff are trained to properly disinfect non-critical medical equipment as required at the Morristown VA Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Morristown VA Clinic staff protect patient-identifiable information on laboratory specimens during transport.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that the information technology server closet at the Morristown VA Clinic is maintained according to information technology safety and security standards.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that managers ensure that all staff at the Morristown VA Clinic are trained to safely evacuate using all exit routes from the building.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Marion VA Medical Center, Marion, Illinois
|
15-00177-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2016
We recommended that managers ensure that safety data sheets are current at the Paducah VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2016
We recommended that managers ensure staff can access the electronic version of safety data sheets at the Paducah VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2016
We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Paducah VA Clinic in accordance with Joint Commission standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Paducah VA Clinic to the parent facility.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
|
15-00622-06

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Cardiopulmonary Resuscitation Subcommittee review each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Operating Room Management Council meet monthly, include the Chief of Staff and Surgical Quality Nurse as members, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Operating Room Management Council review all surgical deaths with identified problems or opportunities for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Infection Prevention and Control Sub-Committee document follow-up on actions implemented to address identified problems.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
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: 4/22/2016
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that facility managersensure designated employees receive evacuation device training and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for users and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that radiologists document the radiation dose in the Computerized Patient Record System and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that employees consistently use appropriate note titles to document advance directive screening and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the facility consistently perform continuing stay reviews on at least 75 percent of patients in acute beds.
Healthcare Inspection – Access to Urology Service, Phoenix VA Health Care System, Phoenix, AZ
|
14-00875-03

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2016
We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that resources are in place to deliver timely urological care to patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that non-VA care providers’ clinical documentation is available in the electronic health records in a timely manner for Phoenix VA Health Care System providers to review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that the cases identified in this report are reviewed, and for patients who suffered adverse outcomes and poor quality of care, confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
Healthcare Inspection – Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon
|
15-00506-535

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the Acting Under Secretary for Health perform a quality review of the Chief of Surgery's colonoscopies performed in the prior Veterans Health Administration facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the Acting Under Secretary for Health revise the Veterans Health Administration Colorectal Cancer Screening directive to include standardized documentation of quality indicators based on professional society guidelines and published literature (including but not limited to photodocumentation of anatomical landmarks establishing cecal intubation and documentation of cecal withdrawal times).
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the Acting Under Secretary for Health consider adding photodocumentation of cecal intubation and cecal withdrawal time to the standardized criteria for quality colonoscopy for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the System Director ensure patient notification of diagnostic test results within the required timeframe, particularly for critical results, and that clinicians document notification.
Review of Alleged Improper Pay at VHA's Hudson Valley Health Care System
|
15-02053-537

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System conducts a review of all Federal Wage Service employees’ official duty stations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System takes action to correct any inappropriate Federal Wage Service employees’ official duty stations and wage rates.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System provides training to all management and Human Resources personnel on how to correctly determine an employee’s official duty station.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System develops procedures to monitor the accuracy of Federal Wage Service employees’ official duty station.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2017
We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review and consult appropriate VA offices, including the Office of General Counsel, to determine whether administrative action is appropriate for those officials in the Engineering, Environmental Management, and Human Resources Services who did not adequately review or correct employees’ official duty stations in response to the 2014 Office of Human Resources and Administration’s request for verification of all employees’ official duty stations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,555,318.00
Healthcare Inspection – Alleged Suicides and Inappropriate Changes to Mental Health Treatment Program, Coatesville VA Medical Center, Coatesville, Pennsylvania
|
13-04038-521

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that the Facility Director coordinate with Veterans Health Administration leadership regarding the establishment of a Psychosocial Rehabilitation and Recovery Center.
Review of VBA's Alleged Mismanagement of Unemployability Benefits at VARO Seattle, Washington
|
15-02745-522

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended that the Pacific District Director convene an administrative investigation board to determine why VA Regional Office management was unaware that Intake Processing Center staff had stored unprocessed mail for several months without action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended the Pacific District Director convene an administrative investigation board to determine why staff responsible for managing mail did not seek assistance for processing employment questionnaires for several months.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended the VA Regional Office Director conduct refresher training for staff responsible for processing mail with emphasis on processing employment questionnaires.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2015
We recommended the Under Secretary for Benefits implement a plan that requires audit trails coexist with corrective action plans when areas of mismanagement or data manipulation are identified at VA Regional Offices.
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