All Reports

Healthcare Inspection - Review of Solo Physicians’ Professional Practice Evaluations in Veterans Health Administration Facilities
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15-00911-362

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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 ensure that gastroenterology, pathology, nuclear medicine, and radiation oncology program offices define specialty specific criteria or monitors for use in Focused and Ongoing Professional Practice Evaluations and require consistent application across the Veterans Health Administration and that program offices monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health require a process to obtain input for evaluating professional practice from another physician in the same specialty when a physician is the only one of any specialty at a facility and require each Veterans Integrated Service Network to monitor compliance.
Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet
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14-04705-62

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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 conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
We recommended that after reviewing the circumstances of any inappropriate resolution of consults, the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
Healthcare Inspection - VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid Therapy
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14-00895-163

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that the practice of prescribing acetaminophen is in compliance with acceptable standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that VA's practice of routine and random urine drug tests prior to initiating and during take-home opioid therapy to confirm the appropriate use of opioids is in alignment with acceptable standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that follow-up evaluations of patients on take-home opioids are performed timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that opioid patients with active (not in remission) substance use receive treatment for substance use concurrently with urine drug tests.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that VA's practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with acceptable standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that medication reconciliation is performed to prevent adverse drug interactions.
Vet Center Contracted Care Program Review
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12-00040-268

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders receive, review, and approve psychosocial assessments and counseling plans prior to authorizing contracted counseling services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct and document client assessments after 1 year of eligibility for contracted client services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct annual onsite quality reviews for contractors who participate in the Contract for Fee Program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service uses a standard template that includes terms and conditions that are consistent with those in the Readjustment Counseling Service policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service maintains and monitors counseling service contracts in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders authorize contracted counseling services in accordance with Readjustment Counseling Service and Veterans Health Administration policy.
Healthcare Inspection - Review of VHA Follow-Up on Inappropriate Use of Insulin Pens at Medical Facilities
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13-01987-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.
Healthcare Inspection - Prevention of Legionnaires’ Disease in VHA Facilities
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13-01189-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.
Healthcare Inspection - Evaluation of Cataract Surgeries and Outcomes in VHA Facilities
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11-02487-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.
Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities
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11-02585-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that VHA program officials provide additional guidance on what constitutes disruptive behavior and establish common terminology.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that VHA program officials develop guidelines for what information VHA facilities should document regarding disruptive incidents and where this information should be documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health ensure that VHA facilities implement procedures to ensure more timely assignment of Category I PRFs.
Healthcare Inspection – Foot Care for Patients with Diabetes and Additional Risk Factors for Amputation
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11-00711-74

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.
Healthcare Inspection - Inpatient and Residential Programs for Female Veterans with Mental Health Conditions Related to Military Sexual Trauma
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12-03399-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health review existing VHA policy pertaining to authorization of travel for veterans seeking MST related MH treatment at specialized inpatient/residential programs outside of the facilities where they are enrolled.
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