Date Issued
|
Report Number
14-00612-167
All Reports
Date Issued
|
Report Number
14-00231-158
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the sink faucet control in the handicap
accessible restroom at the Alpena CBOC meets Americans with Disabilities Act Guidelines and is accessible during regular clinic hours.
No. 2
to Veterans Health Administration (VHA)
We recommended that processes are improved to ensure review
of the hazardous materials inventory occurs twice within a 12-month period at the Alpena and Bad Axe CBOCs.
No. 3
to Veterans Health Administration (VHA)
We recommended processes are strengthened to ensure women
veterans can access gender-specific restrooms without entering public areas at the Bad Axe CBOC.
No. 4
to Veterans Health Administration (VHA)
We recommended that the parent facility includes staff at the Alpena and Bad Axe CBOCs in required education, training, planning, and participation in annual disaster exercise.
No. 5
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Date Issued
|
Report Number
14-00244-147
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Rochester CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that all identified EOC deficiencies at the Rochester CBOC are tracked by the parent facility EOC Committee until resolution.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screens and drinking levels above NIAAA limits.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Date Issued
|
Report Number
13-00991-154
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 2/24/2015
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, review FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.
No. 2
to Office of Management (OM)
Closure Date: 10/22/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, establish policies and procedures to perform recurring reviews of purchase card transactions above the micro-purchase threshold to identify transactions made by cardholders without appropriate warrant authority.
No. 3
to Office of Management (OM)
Closure Date: 5/21/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, revise policies and procedures to verify that purchase card spending limits do not exceed warrant authority limits before issuing individuals purchase cards with spending limits above the micro-purchase threshold.
No. 4
to Office of Management (OM)
Closure Date: 5/21/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, require recurring unauthorized commitment training for purchase cardholders and their approving officials.
No. 5
to Office of Management (OM)
Closure Date: 1/12/2015
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, ensure the Management Quality Assurance Service follow-up on the status of ratification of identified unauthorized commitments.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/7/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, direct Heads of Contracting Activities to perform individual ratification actions for unauthorized commitments identified by the Executive in Charge, Office of Management and Chief Financial Officer’s review of FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/16/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, create and maintain an accurate database of warranted VA contracting officers that includes warrant effective and expiration dates, and specific warrant authority limitations.
No. 8
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/26/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, establish policies and procedures requiring Heads of Contracting Activities to complete ratification actions within a specified time period after the identification of unauthorized commitments.
No. 9
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/26/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, limit institutional ratifications by ensuring every unauthorized commitment meets the ratification review requirements.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 85,600,000.00
Date Issued
|
Report Number
13-04243-151
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that the facility establish a policy for scanning health records and that compliance with the newly established policy be monitored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the dialysis patient care area have an emergency eyewash station.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that the dialysis unit's chemical storage room is locked when unattended and that compliance be monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the clinical laboratory urinalysis section ceiling leak be repaired and that ceiling tiles in the clinical laboratory urinalysis section and blood bank and in the ambulatory surgery medication room be replaced.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the facility establish a policy addressing radiation equipment inspection, testing, and maintenance and fluoroscopy quality control and that compliance with the newly established policy be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that processes be strengthened to ensure that designated x-ray and fluoroscopy employees have radiation exposure monitoring completed annually and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that signs be posted in waiting and procedure rooms within radiology asking female patients to notify staff if they may be pregnant.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/22/2015
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that processes be strengthened to ensure that patients/caregivers are provided medication lists at discharge and that compliance be monitored.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that patients/caregivers are provided with discharge instructions and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that nursing managers monitor the staffing methodology that was implemented in August 2013.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that nurse managers reassess the target nursing hours per patient day for unit 4 East to more accurately plan for staffing and evaluate the actual staffing provided.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that the facility establish an interprofessional pressure ulcer committee.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that patient care areas are clean, that clean and dirty items are stored separately, and that medications are secured at all times and that compliance be monitored.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 1/4/2016
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify restorative nursing interventions as needed, and document the modifications and that compliance be monitored.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for resident transfers.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that processes be strengthened to ensure that staff do not provide medical treatment to residents during meals in the common dining area.
Date Issued
|
Report Number
14-00687-155
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the Surgical Work Group meet monthly.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the facility implement their plan to track OPPEs and present them to the Professional Standards Board within the timeframe required by local policy and that compliance be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that all MSIT members and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response time.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the locked MH units' seclusion room floors have a cushioned surface.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/3/2015
We recommended that nursing managers monitor the staffing methodology implemented in October 2013.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that inspection documentation includes the time of the inspection and the time when corrective actions occurred.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are consistently conducted and documented in Infection Control Committee minutes.
Date Issued
|
Report Number
12-00177-138
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits establish Veterans Service Network Operations Report capabilities to track claims from the date the Veterans Benefits Administration receives and establishes active servicemembers’ claims to the date of Servicemembers’ discharge from military service.
No. 2
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits track and report claims-processing time prior to Servicemembers’ discharge in timeliness performance results for the Quick Start Program or its successor.
No. 3
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits conduct recurring evaluations that identify needed staffing adjustments to ensure sufficient staff are allocated to accomplish the timeliness targets of the Quick Start Program or its successor.
No. 4
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits require Consolidated Processing Site and intake site claims assistants staff obtain periodic training on identifying and processing claims submitted through the Quick Start Program or its successor.
No. 5
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits modify Systematic Technical Accuracy Reviews to include a systematic review of claims processed through the Quick Start Program or its successor.
No. 6
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to analyze trends of systemic issues identified during Quality Review Team and Systematic Technical Accuracy Review evaluations of claims processed through the Quick Start Program or its successor.
No. 7
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits establish policies and procedures requiring Consolidated Processing Site managers to provide staff recurring training on systemic issues identified during trend analyses of Quality Review Team and Systematic Technical Accuracy Review results.
No. 8
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits revise policies and procedures to clarify that evidence must establish a nexus linking veterans’ claimed conditions to military service regardless of diagnosis proximity to discharge.
No. 9
to Veterans Health Administration (VHA)
We recommend the Under Secretary for Benefits require Consolidated Processing Site managers to ensure staff adhere to Veterans Benefits Administration policies related to service connection while processing claims received through the Quick Start Program or its successor.
Date Issued
|
Report Number
13-04474-157
Date Issued
|
Report Number
14-00685-156
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that the MEC document its discussion of unusual findings or patterns from PRC quarterly summary reports.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews 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. 3
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that the facility have a Surgical Work Group that meets monthly, includes the COS as a member, and documents its review of National Surgical Office reports.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that clinicians provide discharge instructions on all aftercare needs to patients and/or caregivers and document this in the EHR and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that processes be strengthened to ensure that clinicians validate patients' and/or caregivers' understanding of the discharge instructions they provide.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/1/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/23/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/6/2015
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/6/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
Date Issued
|
Report Number
14-00657-144
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/12/2014
We recommend the Under Secretary for Benefits identify and implement options to help alleviate the file storage issues at the regional office in St. Petersburg, FL.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2014
We recommend the Under Secretary for Benefits ensure mailroom personnel date stamp service treatment record files and copies of official military personnel files on the day they are received at the regional office in St. Petersburg, FL.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2014
We recommend the Under Secretary for Benefits identify and implement options to improve timeliness of evidence mail processing at the regional office in St. Petersburg, FL.
Date Issued
|
Report Number
14-00688-162
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that processes be strengthened to ensure that EOC Work Group minutes reflect that actions are taken in response to identified deficiencies.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the facility establish a policy for the safe use of fluoroscopic equipment and that compliance with the newly established policy be monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/17/2014
We recommended that processes be strengthened to ensure that all designated x-ray/fluoroscopy employees receive annual fluoroscopy safety training.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/17/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/20/2015
We recommended that processes be strengthened to ensure that restorative nursing staff consistently document weekly and monthly notes according to local policy and that compliance be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/20/2015
We recommended that processes be strengthened to ensure that providers are notified of critical laboratory and abnormal radiology test results/values within the expected timeframe and that notification is documented in the EHRs.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/13/2015
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the EHRs.
Date Issued
|
Report Number
13-03213-152
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health withhold funding for new mobile medical units until a comprehensive assessment is conducted to assess factors, such as the current composition of the mobile medical unit fleet, services provided, operational days and costs, and the effect on rural veterans’ access to health care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health assign responsibility for developing mobile medical unit policies, objectives, and strategy, and for providing program oversight.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health assign responsibility for maintaining operational data on mobile medical units to ensure mobile medical unit resources can be used as part of VHA’s emergency preparedness plan.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended the Under Secretary for Health publish necessary policy and guidance to provide for effective and efficient mobile medical unit operations.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended the Under Secretary for Health implement a mechanism to ensure that mobile medical unit-specific operations and financial data, such as patient workload, services provided, and costs, are collected in the Veterans Health Administration’s Decision Support System.
Date Issued
|
Report Number
14-00895-163
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that the Under Secretary for Health ensure that the practice of prescribing acetaminophen is in compliance with acceptable standards.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
We recommended that the Under Secretary for Health ensure that VA's practice of routine and random urine drug tests prior to initiating and during take-home opioid therapy to confirm the appropriate use of opioids is in alignment with acceptable standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that follow-up evaluations of patients on take-home opioids are performed timely.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that opioid patients with active (not in remission) substance use receive treatment for substance use concurrently with urine drug tests.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that VA's practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with acceptable standards.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/28/2015
We recommended that the Under Secretary for Health ensure that medication reconciliation is performed to prevent adverse drug interactions.
Date Issued
|
Report Number
14-00236-153
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/15/2014
We recommended that fire drills are performed every 12 months at the Johnstown CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/6/2014
We recommended that medications are secured and only accessible by those individuals who either dispense or administer medications at the State College CBOC and that compliance is monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/6/2014
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Johnstown CBOC.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/9/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Date Issued
|
Report Number
13-00054-148
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that completed improvement actions related to protected peer review are reported to the Peer Review Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facility observation bed processes are guided by comprehensive policies and that usage is monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that reviews of inpatients’ continuing stays are consistently completed.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ scanning processes are guided by comprehensive policies, that medical information is properly scanned into patients’ electronic health records, and that compliance is monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for thorough review of individual resuscitation episodes.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
Date Issued
|
Report Number
14-01072-140
Date Issued
|
Report Number
14-01073-139
Date Issued
|
Report Number
14-01288-145
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that inspections are completed at the designated frequency and by required members, that all required elements are documented, and that construction sites comply with applicable VA and Occupational Safety and Health Administration requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that contractor tuberculosis risk assessments are conducted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that facilities establish Construction Safety Committees; develop and implement written policies addressing committee responsibilities; assure required committee membership and participation; and ensure meeting minutes include consistent documentation of inspection results, follow-up actions to resolve unsafe conditions, and tracking of actions to completion.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/27/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that Infection Control Committee meeting minutes include consistent documentation of construction-related infection control surveillance activities and any necessary follow-up actions to identified trends or problems.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that designated facility staff receive required initial and biennial construction safety training.
Date Issued
|
Report Number
13-00589-137
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Under Secretary for Health establish a process to track VA medical facilities' expenditure of NRM funds toward addressing the maintenance backlog.
No. 2
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Under Secretary for Health establish procedures to ensure VA medical facilities projects address the Facility Condition Assessment deficiencies as approved under the Strategic Capital Investment Plan.
No. 3
to Office of Management (OM)
Closure Date: 5/20/2015
We recommend the Under Secretary for Health establish procedures to identify non-recurring maintenance projects that are not meeting milestones to ensure that timely corrective actions are taken.
No. 4
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Under Secretary for Health develop clearly defined criteria for assigning risk levels to building infrastructure systems reviewed by Facility Condition Assessment contractors.
No. 5
to Office of Management (OM)
Closure Date: 2/19/2015
We recommend the Executive in Charge for the Office of Management and Chief Financial Officer increase financial accountability by implementing standardized accounting procedures for tracking NRM projects' financial performance.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/15/2014
We recommend the Principal Executive Director, Office of Acquisition, Logistics and Construction instruct contract engineers to assign risk levels to identified maintenance deficiencies based on VHA criteria.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/15/2014
We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction review Facility Condition Assessment estimating processes and procedures to ensure compliance with industry best practices.
No. 8
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/15/2014
We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction review historical project costs to determine an effective adjustment factor to better estimate contract costs to complete the repair of identified maintenance deficiencies.
Date Issued
|
Report Number
14-00689-142
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are completed within the timeframe required by facility bylaws.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that EOC Committee and Administrative Executive Committee minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that medication/supply carts are secured at all times and that compliance be monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that Nursing Service is represented at Radiation Safety Committee meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that managers initiate timely actions to address deficiencies identified during annual physical security surveys.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that pharmacy inspections are consistently completed on the same day they were initiated and that compliance be monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections, daily public area inspections and bed checks, and weekly contraband inspections are completed and documented and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that medications in resident rooms on the MH RRTP units are secured and daily inspections for this are documented and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that processes be strengthened to ensure that written agreements acknowledging MH RRTP resident responsibility for medication security are documented and that compliance be monitored.