All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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15-00138-392

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that employees at the Haverhill CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Haverhill CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that the information technology server closet at the Haverhill CBOC is maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that testing of the panic alarm system is conducted at the Haverhill CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio
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15-00595-417

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
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: 1/12/2016
We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, that the committee document the screening reviews, and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility include Social Work Service, Chaplain Service, and the Rehabilitation Medicine and Service Care Line in the review of electronic health record quality.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that facility managers ensure that patient care areas are clean and in good repair and that areas under sinks are not used for storage and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that the recently implemented Consult Management Committee continue to meet regularly to review consult data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and includes all required elements and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that facility managers ensure the Domiciliary and Psychosocial Residential Rehabilitation Treatment Programs are clean and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the Domiciliary Residential Rehabilitation Treatment Program have a Class K fire extinguisher available in the kitchen used by residents.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility correct the deficiencies identified during monthly Domiciliary Residential Rehabilitation Treatment Program self-inspections and that documentation reflects correction.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that Domiciliary Residential Rehabilitation Treatment Program managers ensure residents secure medications in their rooms and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinicians ensure that the safety plans for all patients assessed to be at high risk for suicide specifically address suicidality and that facility managers monitor compliance.
Healthcare Inspection – Vascular Surgery Resident Supervision, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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14-04037-404

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the System Director ensure the timeframe for supervisor co-signature of inpatient resident progress notes is defined and documented.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the System Director ensure that attending surgeons cosign resident progress notes timely.
Healthcare Inspection – Alleged Poor Quality of Care and Refusal to Pay for Lung Transplantation, Iowa City VA Health Care System, Iowa City, Iowa
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15-01968-424

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2016
We recommended that the Interim Under Secretary for Health review how the Veterans Health Administration compensates non-VA facilities for lung transplantation to ensure that reimbursement is appropriate for the services performed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended that the System Director conduct a focused professional practice evaluation of the care provided by attending physicians at the facility during the patient’s fall 2014 hospitalization.
Healthcare Inspection – Alleged Dental Service Scheduling and Other Administrative Issues, VA Palo Alto Health Care System, Palo Alto, CA
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14-04755-428

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2016
We recommended that the Veterans Integrated Service Network Director review the dental program after corrective actions have been implemented to ensure that dental care at the system is timely and of high quality.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2016
We recommended that the System Director monitor the dental clinic to ensure that patients receive appropriate access to care, as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that the System Director implement recommendations as described in the 2011 Veterans Health Administration Office of Dentistry Workforce Study regarding staffing in dental clinics.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that the System Director ensure timely delivery of prosthetic devices and documentation of each step in the process and monitor compliance.
Healthcare Inspection – Alleged Consult Processing Delay Resulting in Patient Death, VA Eastern Colorado Health Care System, Denver, Colorado
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14-04049-379

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the NVCC consult process is clearly defined, the facility has appropriate processes in place to identify and address potential delays, and that compliance is monitored.
Healthcare Inspection – Alleged Short-Stay Rehabilitation Unit Concerns, Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
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15-01445-400

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2016
We recommended that the Facility Director ensure that the assessments for patients screened for admission by the facility physiatrist consultant are documented in the electronic health records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that the Facility Director ensure Valor Center screening and admission policies are consistent with Valor Center practices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that the Facility Director ensure that all relevant staff are notified of planned Valor Center admissions to allow staff sufficient time to make appropriate plans for required care and services.
Healthcare Inspection – Scheduling, Staffing, and Quality of Care Concerns at the Alaska VA Healthcare System, Anchorage, AK
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14-04077-405

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement an action plan based on ongoing monitoring of access performance measures that includes recruitment and retention, and ensure continued provision of primary care by a permanent provider at the Mat-Su VA Community Based Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement contingency plans for ensuring patients receive continuity of and access to appropriate primary care during periods of inadequate resources, extended staff absences, staff turnover, understaffing, and nature-related events, as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement the requirements of Veterans Health Administration Handbook 1101.10, Patient-Aligned Care Teams, regarding care coordination.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director provide access to care at the Mat-Su VA Community Based Outpatient Clinic in accordance with Veterans Health Administration policy and provider recommendations for follow-up.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement a peer review process consistent with Veterans Health Administration policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the Veterans Integrated Service Network Director ensure the System Director perform peer review and consult regional counsel as appropriate for the cases identified in this report.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement a provider evaluation process consistent with Veterans Health Administration policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director strengthen processes for committee reporting to align with Veterans Health Administration Directive 1026, Enterprise Framework for Quality, Safety, and Value, and system bylaws.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director assess the culture, morale, and leadership issues identified in this report, and take appropriate action as necessary.
Healthcare Inspection – Alleged Quality of Care Issues at the Community Based Outpatient Clinic, Casa Grande, AZ
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14-04260-395

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended that the Southern Arizona VA Health Care System Director ensure that same day access appointments and post hospitalization follow-up appointments at the Casa Grande Community Based Outpatient Clinic are triaged appropriately and timely.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended that the Southern Arizona VA Health Care System Director ensure that processes are strengthened to improve telephone appointment scheduling practices.
Improper Use of Title 38 Section 8153 Contracts to Fund Educational Costs of the Graduate Medical Education Programs of Affiliated Schools of Medicine
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14-04259-409

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/7/2015
We recommend that the Interim Under Secretary for Health rescind VHA Handbook 1400.10.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/7/2015
We recommend that the Interim Under Secretary for Health terminate existing contracts for indirect educational costs awarded under the guidance of VHA Handbook 1400.10.
Healthcare Inspection – Alleged Quality of Care Concerns, Gene Taylor Community Based Outpatient Clinic, Mount Vernon, Missouri
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14-04547-398

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2015
We recommended that the Interim Under Secretary for Health review documentation requirements of Veterans Health Administration Handbook 1907.01 and determine whether the documentation requirements support the obligations placed on VA primary care providers by Veterans Health Administration Directive 2009-038.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Veterans Health Care System of the Ozarks Director ensure that providers evaluate patients and coordinate care provided in the community in accordance with Veterans Health Administration¿s dual care policy.
Combined Assessment Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
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15-00594-389

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that facility managers ensure that credentialing and privileging folders do not contain information that is not allowed and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2015
We recommended that facility managers ensure nurse call systems with portable telephones have alarms that are audible and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2016
We recommended that the facility’s Emergency Operations Plan include how the facility manages patient scheduling.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2016
We recommended that facility managers ensure monthly medication storage area inspections are completed on the medical/surgical acute care unit and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2016
We recommended that facility managers consistently implement corrective actions for issues identified during monthly medication storage area inspections and monitor the changes until issues are fully resolved.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2016
We recommended that facility managers ensure designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2016
We recommended that facility managers ensure initial clinician emergency airway management competency assessment includes documentation of all required elements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2016
We recommended that facility managers ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and monitor compliance.
Healthcare Inspection – Alleged Lapse in Timeliness of Care, West Palm Beach VA Medical Center, West Palm Beach, Florida
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15-00191-406

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended that the Facility Director implement procedures to ensure that unstable patients being transported from one area to another in the facility be monitored safely and accompanied by appropriate personnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2016
We recommended that the Facility Director ensure that Emergency Department and Interventional Radiology nursing staff receive education on handoff communication requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2015
We recommended that the Facility Director ensure that the facility policy for the handoff communication process be reviewed for inclusion of documentation of handoff communication.
Review of Alleged Delays in Care Caused by Patient-Centered Community Care (PC3) Issues
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14-04116-408

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health establish timeliness criteria for submitting authorizations to the Patient-Centered Community Care contractors.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health monitor timeliness of submitting authorizations to Patient-Centered Community Care contractors and take actions to improve timeliness when standards are not met.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health evaluate the Patient-Centered Community Care contractor networks to ensure they are sufficient to meet contract performance requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended the Interim Under Secretary for Health revise contract terms to eliminate the option of scheduling appointments before communicating with the veteran.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors return authorizations if they cannot schedule an appointment within 5 business days of receipt of the authorization.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors return authorizations when they cannot arrange for an appointment to take place within 30 days of the appointment creation date.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors comply with requirements to notify Veterans Health Administration within 14 days of a missed appointment.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health implement a control to ensure Patient-Centered Community Care contractors comply with requirements to return medical documentation within 14 days of the appointment's occurrence.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health implement a mechanism to monitor all authorizations submitted to the Patient-Centered Community Care contractors.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended the Interim Under Secretary for Health revise the Patient-Centered Community Care dashboard to report completed authorizations and the percentage of total authorizations by the specific contractors performing these services.
Healthcare Inspection – Alleged Mental Health Access and Treatment Deficiencies, Brunswick Community Outpatient Clinic, Brunswick, Georgia
|
15-01116-390

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that the Facility Director ensure that clinical staff assign surrogates to manage secure messages as required by Veterans Integrated Service Network 7 policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that the Facility Director ensure that staff comply with Veterans Health Administration policy for scheduling outpatient follow-up appointments, that staff utilize the Recall/Reminder Software application when appropriate, and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2016
We recommended that the Facility Director ensure that community based outpatient clinic staff initiate appropriate follow-up action when a patient is ano show or fails to schedule a follow-up appointment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2016
We recommended that the Facility Director ensure that services outlined in the treatment plan are provided and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2016
We recommended that the Facility Director ensure processes are in place to ensure continuity of the mental health treatment plan in the event of staff departure and/or reassignment and to discuss proposed changes to treatment plans with patients.
Review of Alleged Mismanagement of Medical Supplies at the VA Medical Center, East Orange, New Jersey
|
15-01927-375

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System purchases and maintains medical supplies at normal stock levels.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System conducts a 100 percent wall-to-wall inventory of all Medical Supply Distribution Section inventory storage areas and document results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System uses the results of the wall-to-wall inventory to assess the accuracy of the Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system, and makes adjustments as deemed appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System obtains and mandates the use of one model of barcode scanner to track and maintain medical supply inventory.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure the VA New Jersey Health Care System implements measures to determine reasons discrepancies are occurring in inventories and takes appropriate corrective action before technicians manually adjust the Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 48,100.00
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