All Reports

Healthcare Inspection – Alleged Poor Mental Health Care Resulting in a Patient Death, VA Central Iowa Health Care System, Des Moines, Iowa
|
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
|
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
|
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
|
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

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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 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.
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)
Closure Date: 3/27/2017
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)
Closure Date: 3/27/2017
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.
Combined Assessment Program Review of the VA Boston Healthcare System, Boston, Massachusetts
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15-00078-364

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that the facility develop a plan to complete the conversion from a six-part credentialing and privileging folder to a two-part privileging folder.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that the facility repair damaged floors, ceilings, and walls in patient care areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that facility managers ensure all patient care areas are clean and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that facility managers ensure that all furnishings on the acute behavioral health unit comply with the standards of the VA Mental Health Environment of Care Checklist and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that the facility repair damaged or worn furnishings in patient care areas or remove them from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2016
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: 11/25/2015
We recommended that facility managers ensure all designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that facility managers ensure that oral syringes are available for oral liquid medication administration and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended that the facility revise the stroke policy to require the stroke team to respond in person within 30 minutes of receiving a call and that facility managers fully implement the revised policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2015
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that facility managers ensure that A2 and 3N nurses have 12-lead electrocardiogram competency assessment and validation included in their competency checklists.
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada
|
15-00079-358

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the Intensive Care Unit Committee review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the Environment of Care Committee share patient handling injury data with the newly designated safe patient handling coordinator/champion.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility establish a committee to provide oversight and coordination of electronic health record quality review activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure patient care equipment items and surfaces are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure all designated critical care employees receive annual bloodborne pathogens training and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers ensure walk-off sticky mats are changed as needed to minimize dust and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2015
We recommended that facility managers ensure that the temporary construction barrier is equipped with a self-closing door with a metal frame for worker access.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2016
We recommended that the facility educate employees on the medical and community living center units that intravenous syringes are not to be used to measure oral liquid medications and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility implement an acute ischemic stroke policy that addresses all required items.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that facility managers post stroke guidelines in all required patient care areas.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility report to the Veterans Health Administration 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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that the facility ensure that a qualified physician is present in the Emergency Department at all times, that non-Emergency Department clinicians are assigned inpatient emergency airway management coverage from 9:00 p.m. to 7:00 a.m., and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2015
We recommended that the facility ensure patients with positive colorectal cancer screening test results receive diagnostic testing within the required timeframe and that facility managers monitor compliance.
Audit of Fiduciary Program’s Management of Field Examinations
|
14-01883-371

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/25/2018
We recommended the Under Secretary for Benefits implement a plan to ensure field examination workload is completed in compliance with timeliness standards.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 4/4/2018
We recommended the Under Secretary for Benefits use the percentage of untimely field examinations in addition to the average days pending performance measure to better evaluate completion of field examinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/20/2017
We recommended the Under Secretary for Benefits require hub managers to use Beneficiary and Fiduciary Field System reports to identify and correct unscheduled field examinations at least once per quarter.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/20/2015
We recommended the Under Secretary for Benefits implement a plan to ensure the Beneficiary and Fiduciary Field System’s functionality is enhanced to require a date for scheduled field examinations be entered before exiting the system.
Administrative Investigation, Misuse of Position and Failure to Disclose and to Satisfy Financial Obligations, Veterans Benefits Administration, VA Regional Office, Philadelphia, PA
|
14-04494-347

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommend that the Eastern Area Director confer with the Offices of General Counsel (OGC) and Human Resources (OHR) to take appropriate administrative action, if any, against Ms. Filipov.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommend that the Eastern Area Director confer with OGC and OHR to ensure that Ms. Filipov receives refresher ethics training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommend that the Eastern Area Director confer with the Offices of General Counsel (OGC) and Human Resources (OHR) to take appropriate administrative action, if any, against Mr. Hodge.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommend that the Eastern Area Director confer with OGC and OHR to ensure that Mr. Hodges receives refresher ethics training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommend that the Eastern Area Director confer with OGC to ensure Mr. Hodge's Confidential Financial Disclosure Reports for past years are reviewed and any necessary action is taken as a result of that review.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Beckley VA Medical Center, Beckley, West Virginia
|
14-04398-340

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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 Greenbrier County CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that written procedures are available and staff are trained to properly disinfect non-critical medical equipment as required at the Greenbrier County CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Greenbrier County CBOC 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 the staff at the Greenbrier County CBOC receive regular information/updates on their responsibilities in emergency response operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Greenbrier County CBOC participate in scheduled emergency management training and exercises.
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 document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 8
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. 9
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. 10
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.
Healthcare Inspection – Administrative and Quality of Care Concerns, Martinsburg VA Medical Center, Martinsburg, West Virginia
|
13-04212-346

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the Facility Director ensure that the facility comply with Veterans Health Administration’s and facility test results notification requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the Facility Director ensure that the facility strengthen the root cause analysis process.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2015
We recommended that the Facility Director ensure that the facility evaluate the care of the subject patient with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2015
We recommended that the Facility Director ensure that the facility strengthen and monitor the peer review process.
Combined Assessment Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
|
15-00077-352

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the Surgical Work Group document its review of National Surgical Office reports and surgery performance improvement activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the Surgical Work Group review all surgical deaths with identified problems or opportunities for improvement.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that the Accident Review Board provide oversight of the safe patient handling program and gather, track, and share patient handling injury data.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that the Medical Executive Board analyze reports of electronic health record quality review results at least quarterly and include most services in the review of electronic health record quality.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility document functionality checks of the community living center's elopement prevention system at least every 24 hours and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that facility managersensure Emergency Department/urgent care center monthly medication storage area inspections are completed and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility revisethe policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that requestorsconsistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians complete National Institutes of Health stroke scales for each stroke patient within the expected timeframe and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that facility managers post stroke guidelines on the medical intensive care unit/cardiac care unit, the surgical intensive care unit, 2 West - medicine/surgery, 4 West - medicine/surgery, and the progressive care unit.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility collect and report to the Veterans Health Administration 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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that Radiology Service revise the computed tomography scan on-call policy to require a 30-minute reporting time.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients before placement on the out of operating room airway management coverage list and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended that the Facility Director ensure designated clinicians have properly completed and granted privileges or scopes of practice.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2015
We recommended that the facility ensure that subordinate committees report data to the appropriate oversight committee and that the oversight committee reviews and analyzes data, takes appropriate action, and tracks actions to completion.
Inspection of VA Regional Office Pittsburgh, Pennsylvania
|
14-04878-205

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 Benefits Administration (VBA)
Closure Date: 1/12/2016
We recommended the Pittsburgh VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/12/2016
We recommended the Pittsburgh VA Regional Office Director conduct a review of the 352 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommended the Pittsburgh VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Inspection of VA Regional Office Indianapolis, Indiana
|
14-04876-204

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 Benefits Administration (VBA)
Closure Date: 1/29/2016
We recommended the Indianapolis VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications to request medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2016
We recommended the Indianapolis VA Regional Office Director conduct a review of the 353 temporary 100 percent disability evaluations remaining from their inspection universe as of September 2, 2014, and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2016
We recommended the Indianapolis VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for Special Monthly Compensation and ancillary benefits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/22/2015
We recommended the Indianapolis VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Federal Information Security Management Act Audit for Fiscal Year 2014
|
14-01820-355

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 Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology fully develop policy to address Federal requirements and implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central Governance Risk and Compliance tool to justify closure of Plans of Action and Milestones. (This is a modified repeat recommendation from last year.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a modified repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnections, boundary, and ownership information. (This is a modified repeat recommendation from last year.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement improved processes for updating key security documents such as risk assessments, Privacy Impact Assessments, and security control assessments on an annual basis and ensure all required information accurately reflects the current environment. (This is a modified repeat recommendation from last year.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement periodic access reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement two-factor authentication for remote access throughout the agency. (This is a repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA¿s network infrastructure, database platforms, and Web application servers. (This is a modified repeat recommendation from last year.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA¿s Web applications, database platforms, network infrastructure, and work stations. (This is a modified repeat recommendation from last year.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement improved processes for monitoring standard security configuration baselines for all VA operating systems, databases, applications, and network devices. (This is a modified repeat recommendation from last year.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement improved network access controls to ensure medical devices and tenant networks are appropriately segregated from general networks and mission-critical systems. (This is a new recommendation)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology consolidate the security responsibilities for tenant networks present under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a new recommendation)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Executive in Charge for Information and Technology implement procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (This is a modified repeat recommendation from last year.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement processes to ensure information system contingency plans are updated with the required information. (This is a modified repeat recommendation from last year.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite for storage. (This is a repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and exchanges for unauthorized activity. (This is a modified repeat recommendation from last year.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement and monitor incident response metrics to assist in tracking and remediating all cybersecurity events. (This is a new recommendation)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop a listing of approved software and implement continuous monitoring processes to identify and prevent the use of unauthorized application software, hardware, and system configurations on its networks. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement procedures for overseeing contractor-managed, cloud-based systems and ensuring information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from last year.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating the Federal Information Security Management Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure all users with VA network access participate in and complete required VA-sponsored security awareness training. (This is a repeat recommendation from prior years.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop guidance and procedures to integrate information security costs into the capital planning process while ensuring traceability of Plans of Action and Milestones remediation costs to appropriate capital planning budget documents.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure risk assessments accurately reflect the current control environment, compensating controls, and the characteristics of the relevant VA facilities.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology update all applicable position descriptions to better describe position sensitivity levels, and improve documentation of employee/contractor personnel records of ¿Rules of Behavior¿ and annual privacy training certifications.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology ensure appropriate levels of background investigations be completed for all applicable VA employees and contractors in a timely manner, implement processes to monitor and ensure timely reinvestigations on all applicable employees and contractors, and monitor the status of the requested investigations.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology reduce wireless security vulnerabilities by ensuring sites have up-to-date mechanisms to protect against interception of wireless signals and unauthorized access to the network, and ensure the wireless network is segmented from the general network.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology identify and deploy solutions to encrypt sensitive data and resolve clear text protocol vulnerabilities.
Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri
|
15-00075-351

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Facility Director continue to chair Quality Executive Board meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the Medical Executive Board and the Facility Director consistently review and approve all privilege forms annually and all revised privilege forms and document the review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have properly approved/signed privilege forms.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility implement a policy that defines Surgical Work Group membership.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Surgical Work Group document its review of National Surgical Office reports and its review of all surgical deaths with identified problems or opportunities for improvement.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that clinicians report all critical incidents through the facility’s adverse event reporting process.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2017
We recommended that the facility review the quality of entries in the electronic health record and analyze data at least quarterly.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility fully implement the new quality control policy for scanning and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that Environment of Care Committee minutes include discussion regarding environment of care rounds deficiencies and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility store oxygen tanks in a manner that distinguishes between empty and full tanks and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure all electrical gang boxes have the appropriate covers installed.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility promptly remove outdated commercial supplies from sterile supply rooms and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility label medications in accordance with local policy and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility inspect alarm-equipped medical devices according to local policy and the manufacturers’ recommendations and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the facility document functionality checks of the community living center’s elopement prevention system at least every 24 hours and conduct and document annual complete system checks and that facility managers monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility inspect and tag critical medical equipment in the community living center and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that facility managers ensure crash cart logs contain the correct lock numbers and monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure the look-alike and sound-alike medication list is available for staff reference in all areas.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure the high-alert medication list is available for staff reference.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility create/designate a committee to oversee consult management.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Medicine, Mental Health, Surgical, and Rehabilitation Services’ Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that Medicine, Mental Health, Surgical, and Rehabilitation Services designate an individual to review and manage consults.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
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. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
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. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility revise the stroke policy to address a stroke team and data gathering for analysis and improvement and that facility managers fully implement the revised policy.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the facility collect and report to the Veterans Health Administration 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. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that Radiology Service revise the computed tomography scan, magnetic resonance imaging/magnetic resonance angiograms, and radiology interpretation on-call policy to require a 30-minute reporting time.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
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. 40
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
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. 41
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management have a statement related to emergency airway management included in an approved scope of practice.
No. 42
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
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. 43
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that facility managers strengthen processes to minimize a repeat occurrence in which non-privileged providers perform intubations and in instances of occurrence, initiate root cause analyses.
No. 44
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that facility managers ensure that only authorized patients, staff, and visitors access the Domiciliary Residential Rehabilitation Treatment Program.
No. 45
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that facility managers ensure that the Domiciliary Residential Rehabilitation Treatment Program does not have closed circuit television in treatment areas.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Puget Sound Health Care System, Seattle, Washington
|
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.
Combined Assessment Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
|
15-00076-350

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: 10/22/2015
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 Boston Healthcare System, Boston, Massachusetts
|
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.
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