All Reports

Combined Assessment Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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15-00076-350

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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 Accident Review Board gather, track and share patient handling injury data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the facility include most services and program areas in the review of electronic health record quality.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommended that the facility institute unique refrigerator bin storage practices for look-alike and sound-alike medications in all areas and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2015
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each patient and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and completion of a written test and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Puget Sound Health Care System, Seattle, Washington
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15-00112-338

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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 managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the North Olympic Peninsula CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Boston Healthcare System, Boston, Massachusetts
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15-00126-342

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2015
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Causeway VA Clinic to the parent facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
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: 9/24/2015
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: 9/24/2015
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: 5/14/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
FY 2014 Review of VA’s Compliance With the Improper Payments Elimination and Recovery Act
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14-03380-356

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2016
We recommended the Interim Under Secretary for Health ensure implementation of the revised sampling plan for the Civilian Health and Medical Program of the Department of Veterans Affairs to address sample outliers and adjust the program¿s reduction target to a reasonably achievable level, if necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/16/2016
We recommended the Under Secretary for Benefits monitor the results of the Veterans Benefits Administration¿s revised testing plans for the Compensation, Pension, Montgomery G.I. Bill, and Vocational Rehabilitation and Employment programs and adjust the reduction targets to reasonably achievable levels, if necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/16/2016
We recommended the Under Secretary for Benefits implement revised testing plans for the Post-9/11 G.I. Bill and its other reported Education programs that ensure valid and auditable estimates of improper payments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/27/2016
We recommended that the Acting Assistant Secretary for Management improve the risk assessment guidance and instructions to include an assessment of risk associated with contracting activities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/1/2017
We recommended that the Acting Assistant Secretary for Management perform risk assessments for programs with a high concentration of vendor payments using revised procedures that include contracting risk.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/8/2016
We recommended that the Under Secretary for Benefits ensure thorough testing of sample items used to estimate improper payments for the Compensation program.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/9/2015
We recommended that the Under Secretary for Benefits consult with the Office of Management and Budget regarding the potential designation of the Compensation program as a high-priority program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/16/2016
We recommended that the Under Secretary for Benefits use the annual Department of Defense drill pay matching file to identify improper drill pay-related payments in its Compensation and Pension program samples to ensure accurate and auditable reporting.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2016
We recommended that the Interim Under Secretary for Health improve test procedures for the Non-VA Medical Care and Purchased Long Term Services and Support programs by verifying the existence of valid contracts that support payments for these programs.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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15-00124-227

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire drills are performed every 12 months at the O’Neill VA Clinic.
No. 2
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. 3
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 5
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Palo Alto Health Care System, Palo Alto, California
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15-00110-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2015
We recommended that employees at the Fremont CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2016
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Fremont CBOC to the parent facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Roseburg Healthcare System, Roseburg, Oregon
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15-00129-339

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2016
We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Brookings CBOC in accordance with Joint Commission standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that managers monitor hand hygiene compliance at the Brookings CBOC and report compliance levels to the Infection Control Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that the information technology staff maintain the information technology server closet at the Brookings CBOC according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2017
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: 8/25/2016
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: 8/25/2016
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)
Closure Date: 9/22/2015
We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coach training as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Alleged Mismanagement of Radiologists Interpretations at Central Arkansas Veterans Healthcare System
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14-04493-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended the Interim Veterans Integrated Service Network 16 Director review TalkStation data showing the time interpretations started and ended to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2015
We recommended the Interim Veterans Integrated Service Network 16 Director require the Central Arkansas Veterans Healthcare System to establish policy on an official tour of duty for weekends to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended the Interim Veterans Integrated Service Network 16 Director annually review the Teleradiology Reading Center agreement and certify that services are still needed, qualified individuals in the specialty are not available locally, and other business options have been considered for obtaining services.
Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California
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15-00032-226

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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 the facility establish a committee to provide oversight of the safe patient handling program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
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: 12/16/2015
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that facility managers ensure personal protective equipment gowns, eye protection, and masks are available in various sizes in patient care areas and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that facility managers ensure all designated critical care and community living center employees receive annual bloodborne pathogens training and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the facility conduct initial patient safety screenings prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2015
We recommended that facility managers post stroke guidelines on the critical care and medical/surgical units.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that the facility report to the Medical Executive Board the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that clinicians obtain cardiac markers, prothrombin time/international normalized ratio, and partial thromboplastin time while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
Review of VA's Patient-Centered Community Care (PC3) Contracts' Estimated Costs Savings
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14-02916-336

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended the Interim Under Secretary for Health assign an accountable senior executive to prepare and document revised Patient-Centered Community Care price analyses and determine if VA will realize any cost savings during the future option years of the contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended the Interim Under Secretary for Health develop an action plan to address low PC3 contract utilization rates.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/9/2015
We recommended the Executive Director, Office of Acquisition, Logistics, and Construction ensure all required contract documents are maintained in the official Patient-Centered Community Care contract files in accordance with Federal Acquisition Regulation and hold the contracting officer accountable for ensuring complete and accurate information is maintained in the Electronic Contract Management System.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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15-00114-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2015
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)
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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