All Reports

Healthcare Inspection – Quality and Coordination of Care Concerns at Two Veterans Integrated Service Network 15 Facilities
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14-04547-401

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health take steps to prevent prescriptions from being dispensed to deceased veterans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Kansas City VA Medical Center Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Kansas City VA Medical Center Director ensure that processes be strengthened so medication reconciliation is consistently completed and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Kansas City VA Medical Center Director conduct peer reviews of this patient’s care, to include the evaluation and treatment of recurrent falls and the coordination of care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Harry S. Truman Memorial Veterans’ Hospital Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
Combined Assessment Program Summary Report - Evaluation of Selected Requirements in Veterans Health Administration Community Living Centers
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15-01721-382

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents who may be candidates for restorative nursing services, the interdisciplinary team documents the reason the resident is not receiving the services or other activities to promote functional status.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents receiving or supposed to receive restorative nursing services, the interdisciplinary team documents goals in their care plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2017
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that nursing employees provide and document restorative nursing services in accordance with the care plan, and if they do not provide the services, they document the reason.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees complete required restorative summary notes and that the Associate Chief Nurse or designee monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents not progressing toward restorative goals, the interdisciplinary team reassesses the resident care plan and/or adjusts goals and interventions as necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that Physical Medicine and Rehabilitation therapists discharging residents from therapy document hand-off communication with nursing employees to ensure interventions continue or are discontinued, as applicable.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility managers provide and document nursing employee training on range of motion and transfers.
Healthcare Inspection – Evaluation of a Patient’s Care and Disclosure of Protected Information, Atlanta VA Medical Center, Decatur, Georgia
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15-02276-391

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2016
We recommended that the Interim Under Secretary for Health evaluate options that would allow managers to identify individuals who access non-sensitive patient electronic health records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that Mental Health Assessment Team appointments are scheduled within required timeframes, that patients are properly notified of those appointments, and that appropriate follow-up is documented when patients miss Mental Health Assessment Team appointments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that Housing and Urban Development-VA Supportive Housing program contacts or home visits occur as outlined in the patient's treatment plan.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that patient record flags identifying patients at risk for suicide are placed promptly and that required high-risk protocols, including weekly contacts, are implemented and documented accordingly.
Community Based Outpatient Clinics Summary Report ─ Evaluation of Medication Oversight and Education at Community Based Outpatient Clinics and Other Outpatient Clinics
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15-01297-368

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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 Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians perform and document medication reconciliation at each outpatient episode of care when a new medication is prescribed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently provide and document patient education for new outpatient medications.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently assess and document outpatients' understanding of medication education.
Healthcare Inspection – Care of an Urgent Care Clinic Patient, Tomah VA Medical Center, Tomah, Wisconsin
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15-02456-396

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Under Secretary for Health review current acute stroke treatment policies, and assess the use of telehealth evaluation and more aggressive local treatment in patients presenting to rural and/or low complexity VHA facilities with signs and symptoms of an acute stroke.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Under Secretary for Health review processes to improve the ability to identify unauthorized access to VA medical records.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Under Secretary for Health evaluate the complex rules related to reimbursement for a veteran’s emergency care at non-VA facilities, and determine if changes in policy or law would make it more likely that veterans would make decisions on where to seek emergency care based upon medical circumstances, rather than fear of adverse financial impact.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that patients and their families are educated about the services the UCC is equipped to provide.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that employees who are involved in assessing and treating stroke patients receive the web-based acute ischemic stroke training required by the facility and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2016
We recommended that the Facility Director ensure that transfer agreements are established as required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director review and evaluate computerized tomography scanner routine maintenance schedules to determine if routine maintenance can be conducted during periods of traditionally low utilization.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure Urgent Care Clinic processes are strengthened to reduce door-to-triage timeliness.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Facility Director ensure that appropriate staff receive Emergency Department Integration Software training.
Healthcare Inspection – Mismanagement of Mental Health Consults and Other Access to Care Concerns, VA Maine Healthcare System, Augusta, ME
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14-05158-377

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2015
We recommended the Facility Director remove the language in the Computerized Patient Record System outpatient psychological testing consult that may be interpreted as instructing providers not to enter a consult.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended the Facility Director reevaluate and make the appropriate changes to the methods for referring patients for mental health care, including the extent to which the consult package is being used appropriately.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended the Facility Director ensure that mental health consults are reviewed and closed in accordance with Veterans Health Administration policy.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended the Facility Director ensure that Veterans Health Administration appointment scheduling guidance is followed and that schedulers utilize the electronic waiting list and give priority to service connected veterans, as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended the Facility Director review all existing mental health wait lists to identify patients who may be at risk because of a delay in the delivery of mental health care and provide the appropriate care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended the Facility Director expand access to mental health services, particularly required evidence-based psychotherapy and intensive case management services.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended the Facility Director ensure that mental health staff is available in the Emergency Department as required by Veteran Health Administration and local policy to avoid potential delays in admission to the inpatient psychiatry unit.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended the Facility Director review guidance provided to staff about meeting performance measures and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
Review of Alleged Improper Advances of VHA Appropriated Funds to the U.S. Government Printing Office
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14-00730-206

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/1/2015
We recommended Deputy Assistant Secretary for Acquisition and Logistics take steps to consult with the Office of General Counsel to remedy the inappropriate expenditure of approximately $2.3 million of expired funds, determine whether VA should de-obligate any outstanding balances, and evaluate the need to return Supply Fund service fees of approximately $5.6 million.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/1/2015
We recommended Deputy Assistant Secretary for Acquisition and Logistics implement a corrective action plan to ensure that fiscal controls are enforced to avoid future misuse of appropriated funds, including inappropriate use of the VA Supply Fund, and the parking of funds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/18/2016
We recommended the Deputy Assistant Secretary for Finance review the fiscal controls in the Financial Management System to ensure data integrity and an audit trail that reflects the occurrence and source of any accounting record changes.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended the Deputy Under Secretary for Health for Operations and Management confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Chief Business Office officials for directing the misuse of approximately $43.1 million of fiscal year 2011 appropriated funds.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/1/2015
We recommended the Deputy Assistant Secretary for Acquisition, Logistics, and Construction confer with the Office of Human Resources and the VA Office of General Counsel to determine the appropriate administrative action to take, if any, against Supply Fund management for circumventing controls over the management of funds.
Combined Assessment Program Summary Report - Evaluation of Medication Oversight and Education in Veterans Health Administration Facilities
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15-00359-374

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians adjust fluoroquinolone doses and/or frequencies consistent with manufacturers' recommendations when patients' estimated glomerular filtration rate values are below targeted thresholds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians providing medication education document the accommodations made to address patients¿ identified learning barriers.
Healthcare Inspection – Quality of Care and Access to Care Concerns, Jack C. Montgomery VA Medical Center, Muskogee, OK
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14-04573-378

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director evaluate the care of the cases discussed in this report with Regional Counsel for possible disclosure(s) to the patient(s) and/or surviving family members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director require the Facility Director to conduct peer reviews of the cases identified in this report and take appropriate action to evaluate clinical competence of the providers involved in these cases based on the results of those reviews and this report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director send a team to evaluate the facility’s Dental Service and oversee the implementation of any recommendations for improvement in scheduling and the general provision of dental care at the facility made by that team.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director provide appropriate and timely neurosurgical consultation services to patients receiving care at the facility consistent with Veterans Health Administration Directive 2008-056, VHA Consult Policy, September 16, 2008.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that all documents that patients and non-VA providers receive regarding maternity/obstetric care and services are reviewed and revised to eliminate ambiguous language.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that providers document all clinically pertinent telephone conversations concerning patient care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Veterans Integrated Service Network and the Facility Director ensure adequate parking space requirements to strengthen a safe work environment, patient satisfaction, and provide optimal safety to patients, visitors, and staff.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network and the Facility Director ensure that Ernest Childers VA Outpatient Clinic access and parking is adequate and safe for patients, visitors, and employees.
Healthcare Inspection – Medication Management Concerns, South Texas Veterans Health Care System, San Antonio, Texas
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15-00425-380

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the System Director ensure that processes be developed to improve storage conditions of compounded sterile products on applicable patient units in an effort to reduce unnecessary waste.
Review of Second Instance of Employee Data Manipulation at the Houston VA Regional Office
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15-02354-220

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear or cancel controls for claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director implement a plan to routinely monitor system controls for pending claims, to prevent further manipulation attempts and ensure staff do not prematurely change or remove controls.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2015
We recommended the Houston VA Regional Office Director submit the 13 remaining and previously unavailable claims the employee cancelled in FY 2013 to OIG for review.
Healthcare Inspection – Alleged Magnetic Resonance Imaging Order Deletion and Record Destruction, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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14-02195-381

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that the Facility Director ensure that Radiology Department managers confirm that ordered magnetic resonance imaging exams are scheduled and completed within the Veterans Health Administration required timeframe.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that the Facility Director require Radiology Department managers to review pending lists of magnetic resonance imaging exams at designated intervals to ensure timely scheduling of these exams and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that the Facility Director ensure Radiology Department managers develop and implement a consistent procedure for canceling magnetic resonance imaging orders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the Facility Director ensure that responsible providers are notified of canceled magnetic resonance imaging orders.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/20/2015
We recommended that the Facility Director ensure that radiology clerical staff accurately annotate reasons for canceling magnetic resonance imaging orders and appointments in the electronic health record.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of North Florida/South Georgia Veterans Health System, Gainesville, Florida
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15-00143-372

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coach training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that clinicians consistently notify patients of their laboratory results within 14 days, per local and VHA policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Chillicothe VA Medical Center, Chillicothe, Ohio
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15-00131-373

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that signage is installed at the Marietta CBOC to clearly identify the location of fire extinguishers obscured from view.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that the information technology server closet at the Marietta CBOC is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Clinic Registered Nurse Managers receive motivational interviewing and health coaching training within the time frame specified by VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that providers in the outpatient clinics receive health coaching training within the timeframe specified by VHA policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that clinicians consistently notify patients of their lab results within 14 days as required by VHA.
Healthcare Inspection – Alleged Poor Mental Health Care Resulting in a Patient Death, VA Central Iowa Health Care System, Des Moines, Iowa
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15-02627-386

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommended that the Interim Under Secretary for Health determine the feasibility and advisability of expanding recovery coordination activities to patients with post-traumatic stress disorder.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2015
We recommended that the Veterans Integrated Service Network Director ensure that the VA Central Iowa Health Care System Director provides all levels of Operation Enduring Freedom/Operation Iraqi Freedom case management services in accordance with Veterans Health Administration policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
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15-00125-367

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Phoenix VA Health Care System, Phoenix, Arizona
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15-00128-359

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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 Southeast VA CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hand hygiene compliance is monitored at the Southeast VA CBOC and reported to the Infection Control Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that examination tables and curtains provide adequate privacy for women veterans at the Southeast VA CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closets at the Southeast VA CBOC are maintained according to information technology safety and security standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Southeast VA CBOC participate in scheduled emergency management training.
No. 6
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. 7
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. 8
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. 9
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. 10
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. 11
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.
Combined Assessment Program Review of the Phoenix VA Health Care System, Phoenix, Arizona
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14-04220-363

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the Surgical Work Group include the Chief of Staff as a member.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients¿ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2017
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians obtain cardiac markers, partial thromboplastin time, and an electrocardiogram while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
We recommended that facility managers ensure that medicine/telemetry unit employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Sierra Nevada Health Care System, Reno, Nevada
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15-00127-357

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: 10/20/2015
We recommended that panic alarms are tested and testing is documented at the Reno East Campus CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
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