All Reports

Combined Assessment Program Review of the VA San Diego Healthcare System, San Diego, California
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14-04227-147

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: 8/21/2015
We recommended that the Procedure and Anesthesia Care Council include the Chief of Staff and Surgical Quality Nurse as members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the facility analyze electronic health record quality data at least quarterly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the quality control policy for scanning include the quality of the source document and alternative means of capturing data when the quality of the source document does not meet image quality controls.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that the facility implement actions to address all high-risk areas and follow up on those actions and ensure Infection and Environmental Control Committee meeting minutes document this.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
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: 8/21/2015
We recommended that the facility consistently 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: 11/4/2015
We recommended that the facility educate employees that intravenous syringes are not to be used to measure oral liquid medications and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure that multi-dose injector pens are not stored as ward stock in patient care areas and that they contain patient specific labels and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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: 8/21/2015
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility complete secondary patient safety screenings for all patients immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
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. 14
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 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the facility ensure appropriate barriers are in place to restrict unauthorized or accidental access to magnetic resonance imaging Zone IV.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians obtain and document informed consent for tissue plasminogen activator and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers post stroke guidelines in all areas where patients may present with stroke symptoms.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that facility managers provide a stroke education program for employees involved in assessing and treating stroke patients and that facility managers monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
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. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2015
We recommended that Radiology Service revise its policy to clearly define the required on-call reporting time for computed tomography scan and magnetic resonance imaging and the on-call response time for radiology interpretation.
Administrative Investigation, Appearance of a Conflict of Interest, Fayetteville VA Medical Center, Fayetteville, NC
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12-03002-102

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2015
We recommend that the Deputy Under Secretary for Health for Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Project Manager.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2015
We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against Mr. Hoffman, Ms. Goolsby, Mr. Galkowski, and Ms. Kaplan.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommend that the DUSHOM ensure Mr. Hoffman, Ms. Goolsby, Mr. Galkowski, Ms. Kaplan, and the Project Manager take refresher ethics training directly related to the matters described in this report.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 2/25/2016
We recommend that OGC review this entire matter from start to end, to include but not limited to, the solicitation of interested property owners, the MST evaluation of properties, property ownership and purchase, and the Project Manager being the project manager with oversight of the construction of the leased healthcare center and determine the appropriate corrective action, if any, to take.
Audit of VHA's Home Telehealth Program
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13-00716-101

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health implement mechanisms that effectively identify demand for Non-Institutional Care services to ensure that veterans who need these services are provided the opportunity to participate in the Home Telehealth Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health develop specific performance measures to promote enrollment of Non-Institutional Care patients into the Home Telehealth Program.
Healthcare Inspection – Inadequate Follow-Up of an Abnormal Imaging Result, Charlotte Community Based Outpatient Clinic, Charlotte, North Carolina
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15-00190-146

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director ensure that clinicians involve patients in the treatment planning process and discuss any proposed changes to treatment plans with patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended that the Facility Director ensure that patients receive education on their medical conditions and that education is documented in the electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2015
We recommended that the Facility Director evaluate the VA care provided to the patient summarized in this report and confer with Regional Counsel regarding the need for possible disclosure.
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon
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14-04222-141

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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 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: 4/29/2016
We recommended that facility managers ensure that privileges granted are appropriate for the practitioners’ skills and training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that when conversions from observation bed status to acute admissions are 25–30 percent or more, the facility reassess observation criteria and utilization.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the Acute Care Advisory Board 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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the facility keep the recipient list for the automated e-mail notification current
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the facility analyze electronic health record data 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: 4/29/2016
We recommended that the facility implement a process for the destruction of original documents.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the Safe Patient Handling Committee report patient handling injury data quarterly.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
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: 2/9/2016
We recommended that the facility designate Automated Data Processing Applications Coordinators to train employees and to manage, implement, and maintain the computerized consult package.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that the facility conduct cardiac arrest, contrast reaction, and fire emergency drills in magnetic resonance imaging and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that Level 2 magnetic resonance imaging personnel and/or radiologists 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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that facility employees regularly test the two-way communication device and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility update local magnetic resonance imaging policies for policy changes and review the policies at least every 3 years and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the facility revise the stroke policy to include clinical protocols or pathways, timeliness of completion and interpretation of computed tomography scans, emergent transfer to the nearest primary stroke center, the difference in approach to patients presenting within the facility’s defined timeframe for tissue plasminogen activator and those presenting outside of that timeframe, and screening for difficulty swallowing prior to oral intake and that facility managers fully implement the revised policy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that facility managers post stroke guidelines in the Emergency Department and community living center and on all inpatient units.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that facility managers provide a stroke education program for employees who assess and treat stroke patients.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that domiciliary employees conduct and document monthly domiciliary self-inspections that include all required elements, submit work orders for items needing repair, and ensure correction of any identified deficiencies and that domiciliary managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that domiciliary employees perform and document contraband inspections, rounds of all public spaces, and inspections for unsecured medications and that domiciliary managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommend that the domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that facility managers ensure that closed circuit television with recording capabilities is installed in all domiciliary public areas.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
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. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements and that facility managers monitor compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the facility ensure that all Emergency Department clinicians and clinicians with moderate sedation privileges have emergency airway management privileges.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
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. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that facility managers ensure quarterly reporting of emergency airway management data to the designated committee.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that facility managers ensure reporting of results of completed Focused Professional Practice Evaluations for all newly hired licensed independent practitioners to the Medical Executive Committee.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that facility managers ensure the Medical Records Committee monitors the copy and paste functions.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that facility managers ensure patient notification of positive colorectal cancer screening test results within the required timeframe and that clinicians document notification.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended that facility managers ensure responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2017
We recommended that facility managers ensure patient notification of diagnostic test results within the required timeframe and that clinicians document notification.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
|
14-04396-142

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Worcester CBOC to the parent facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2015
We recommended that the information technology server closet at the Worcester CBOC is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
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: 8/12/2015
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
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.
Combined Assessment Program Review of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
|
14-04228-144

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy/process for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee minutes reflect sufficient detail regarding corrective actions for identified deficiencies and track corrective actions to closure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged floors and walls in patient care areas.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace damaged furnishings, plumbing fixtures, and windows in patient care areas.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all required Environment of Care Committee members consistently attend committee meetings and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility conduct and document annual complete system checks of the community living center’s elopement prevention system and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Mental Health Service’s Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.
Healthcare Inspection — Alleged Mismanagement of Gastroenterology Services and Quality of Care Deficiencies, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
|
14-04473-132

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that the Facility Director ensure that documentation of procedure results from non-VA GI care providers is obtained and available in the electronic health record for review in a timely and consistent manner.
Audit of Non-VA Medical Care Claims for Emergency Transportation
|
13-01530-137

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2015
We recommended the Interim Under Secretary for Health implement periodic training for non-VA medical care staff to ensure proper determination and use of payment and additional documentation criteria.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2016
We recommended the Interim Under Secretary for Health modify Chief Business Office reviews to include a systematic review of emergency transportation claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2015
We recommended the Interim Under Secretary for Health instruct the eight sampled VA medical facilities to initiate recovery of overpayments and reimbursement of underpayments identified in our audit.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 56,200,000.00
Review of Alleged Misuse of VA Funds to Develop the Health Care Claims Processing System
|
14-00730-126

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended the Interim Under Secretary for Health establish oversight mechanisms to ensure Veterans Health Administration uses medical support and compliance funds in accordance with appropriation laws.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended the Interim Under Secretary for Health seek the return of all medical support and compliance funds used to develop and support the Health Care Claims Processing System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended the Interim Under Secretary for Health deobligate all medical support and compliance funds that remain obligated toward the development of the Health Care Claims Processing System.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended the Interim Under Secretary for Health obtain the appropriate funding to support the development of the Health Care Claims Processing System, if additional system development requirements are unfunded.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2016
We recommended the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to determine if appropriate administrative action should be taken against any senior officials in the Deputy Chief Business Office for Purchased Care's supervisory chain of command, and ensure that action is taken.
Healthcare Inspection — Radiology Scheduling and Other Administrative Issues, Phoenix VA Health Care System, Phoenix, Arizona
|
14-00875-133

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that the Radiology Department uses software that is consistent with VA policy to schedule appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers explore the use of the scheduling system by radiology clerks to ensure that appointments are reflected on patients’ appointment lists and that automated reminder letters and phone calls are generated or initiated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers develop and implement a scheduling policy and a formal training program for clerical staff to ensure consistency in scheduling practices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers assess and monitor clerical needs to ensure all check-in areas are staffed, appointments are scheduled/rescheduled, and phones are answered or calls are returned timely.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that the Interim Facility Director ensure that Radiology Department managers implement the facility’s plan for centralized radiology scheduling and procedures to ensure a timely response to phone calls or messages.
Review of Alleged Data Manipulation at the VA Regional Office Little Rock, Arkansas
|
14-03963-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/4/2015
We recommended the Under Secretary for Benefits adopt a permanent, universal policy for dates of claims that VA Regional Office staff should use to manage disability and benefits claims.
Combined Assessment Program Review of the VA Ann Arbor Healthcare System, Ann Arbor, Michigan
|
14-04226-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that credentialing and privileging folders do not contain information that is not permitted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly and that the Chief of Staff attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Morbidity and Mortality Conference review all surgical deaths with identified problems or opportunities for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility designate a committee to oversee consult management.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings date the forms upon review prior to the scan and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the stroke policy to address timeliness of completion and interpretation of computed tomography scans, timeframe for the availability of the stroke team, and the difference in approach to patients presenting within the facility’s defined timeframe and those presenting outside the defined timeframe and that the facility managers fully implement the revised policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians obtain and document signed informed consent and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that critical care unit employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include that portable videolaryngoscopes be available at all times for use by clinicians.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Combined Assessment Program Review of the Beckley VA Medical Center, Beckley, West Virginia
|
14-04229-130

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the Chief of Staff consistently attend meetings of the newly established Surgical Work Group.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the facility ensure service lines report electronic health record quality data to the Electronic Health Record Committee and that the committee analyze the data at least quarterly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that facility managers ensure patient care areas are clean and in good repair and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that facility managers ensure restrooms in the Emergency Department are clean and in good repair and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that facility managers ensure the nurse call system alarms in the Emergency Department are audible and visual and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that facility managers ensure designated employees receive initial automated dispensing machine training and competency assessment and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that the facility conduct initial patient safety screenings and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that Level 2 personnel document referral to a radiologist of patients identified as having applicable conditions during secondary screening and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
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 and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2015
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
Inspection of the VA Regional Office Boston, Massachusetts
|
14-02689-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations for temporary 100 percent disability evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/16/2015
We recommended the Boston VA Regional Office Director develop and implement a plan to review for accuracy the 189 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)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration’s second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing these claims to identify local training needs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/1/2015
We recommended the Boston VA Regional Office Director provide refresher training for staff on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/16/2015
We recommended the Boston VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director ensure Systematic Analyses of Operations are completed timely according to the annual schedule and that they contain thorough analyses, use appropriate data, and include recommendations with time frames for implementation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2015
We recommended the Boston VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Cincinnati VA Medical Center, Cincinnati, Ohio
|
14-04476-116

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure staff can access the electronic version of safety data sheets at the Florence CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Florence CBOC is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Florence CBOC receive scheduled emergency management training.
No. 4
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. 5
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. 6
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.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
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