All Reports

Inspection of VA Regional Office New York, NY
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14-00383-171

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend the New York VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommend the New York VA Regional Office Director develop and implement a plan to review for accuracy the 320 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: 12/31/2014
We recommend the New York VA Regional Office Director develop and implement a plan to ensure staff comply with VBA and local second-signature requirements for traumatic brain injury claims
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend that the New York VA Regional Office Director implement a plan to ensure staff comply with VARO policy requiring evaluation of higher-level special monthly compensation claims by staff assigned to the Special Operations team.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/31/2014
We recommend the New York VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Healthcare Inspection - Quality of Care and Staffing Concerns, Salem VA Medical Center, Salem, Virginia
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13-03604-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the Facility Director continue to monitor and address increases in post-operative infection rates and take appropriate corrective actions when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2015
We recommended that the Facility Director evaluate the admission process from the emergency department and monitor inter-unit transfer patterns, and take corrective actions as indicated.
Healthcare Inspection – Follow-Up of Mental Health Inpatient Unit and Outpatient Contract Programs, Atlanta VA Medical Center, Decatur, Georgia
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12-03869-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Facility Director ensure that a standardized and facility-wide repository be developed and implemented to monitor patients referred to community service boards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Facility Director strengthen processes to ensure that patients are tracked for follow-up beyond the first contracted mental health care appointment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Facility Director strengthen communication between the facility and the community service boards to better integrate and coordinate medical and mental health aspects of patient care.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Huntington VA Medical Center, Huntington, West Virginia
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14-00905-182

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2015
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Prestonsburg CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that staff consistently provide written medication information as required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2014
We recommended that staff provide medication counseling/education as required. VA OIG
Combined Assessment Program Summary Report – Evaluation of the Controlled Substances Inspection Program at Veterans Health Administration Facilities
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14-01785-184

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that pharmacy physical security surveys are conducted and identified deficiencies are corrected and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that quarterly controlled substances inspection trend reports of identified discrepancies, problematic trends, and potential areas for improvement are completed and provided to facility Directors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that monthly inspections of all non-pharmacy controlled substances areas are conducted and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health ensures that VHA defines in policy acceptable reasons for missed controlled substances area inspections and provides guidance regarding Controlled Substances Coordinator performance of monthly inspections.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate 2 transfers of controlled substances from one storage area to another area, reconcile 1 day’s dispensing from the pharmacy to each automated unit, and verify electronic or written orders for 5 randomly selected dispensing activities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors perform quarterly physical counts of the emergency drug cache and monthly verifications of seals and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate completion of all required drug destruction activities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate accountability for all prescription pads stored in the pharmacy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors conducting outpatient pharmacy inspections verify written prescriptions for 10 percent of (or a maximum of 50) schedule II drugs dispensed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors receive annual training regarding problematic issues identified through external surveys and other quality control measures.
Inspection of the VA Regional Office, Reno, Nevada
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13-04324-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/16/2015
We recommend the Reno VA Regional Office Director conduct a review of the 275 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director ensure required staff receive refresher training on how to identify insufficient traumatic brain injury medical examination reports and return them to the appropriate VA medical facilities for correction.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director conduct training on the proper processing of special monthly compensation and ancillary benefits claims and implement a plan to assess the effectiveness of that training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director develop and implement a plan to ensure adequate and continuous oversight is provided for the timely completion of the annual Systematic Analyses of Operations schedule and the required 11 Systematic Analyses of Operations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director ensure that staff assigned to complete Systematic Analyses of Operations receive training on Veterans Benefits Administration policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/6/2014
We recommend the Reno VA Regional Office Director amend the workload management plan to ensure oversight and prioritization of benefit reduction cases.
Healthcare Inspection – Alleged Preventive Maintenance Inspection Deficiencies, Northern Arizona VA Health Care System, Prescott, Arizona
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13-04592-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the System Director initiate actions to address medical equipment with expired preventive maintenance inspections, that processes be strengthened to identify and track deficiencies to closure, and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the System Director assess staffing in the Biomedical Engineering Department and take appropriate actions to meet the workload requirements.
Follow-up Audit of VBA's 100 Percent Disability Evaluations
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14-01686-185

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommend the Under Secretary for Benefits ensure regional office staff take the appropriate action to review and process the records of all veterans with a temporary 100 percent disability evaluation within 180 days of the veteran’s inclusion on the TRAP report or the veteran’s scheduled exam.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
We recommend the Under Secretary for Benefits ensure regional offices transfer from the Records Management Center all claims folders with temporary 100 percent disability evaluations to the regional office of jurisdiction.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 222,600,000.00
Audit of VBA’s Management of Concurrent VA and Military Drill Pay Compensation
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13-02129-177

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2017
We recommended the Under Secretary for Benefits take measures to ensure drill pay offsets identified after fiscal year 2012 are timely processed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2017
We recommended the Under Secretary for Benefits ensure fiscal years 2011 and 2012 drill pay offsets are processed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Under Secretary for Benefits modify existing information technology systems to more effectively monitor, track, and report on drill pay offset activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/23/2015
We recommended the Under Secretary for Benefits update the cost-benefit analysis regularly and use it to prioritize the processing of drill pay offsets.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2014
We recommended the Under Secretary for Benefits require Systematic Analysis of Operations be completed annually for drill pay matching activities.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 623,100,000.00
VA's Federal Information Security Management Act Audit for Fiscal Year 2013
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13-01391-72

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology fully develop and implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from last year.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central database to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology define and implement clear roles and responsibilities for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a repeat recommendation from last year.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from last year.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnection and ownership information. (This is a repeat recommendation from last year.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement improved processes for updating key security documents such as risk assessments, security impact analyses, and security self-assessments on at least an annual basis and ensure all required information accurately reflects the current environment and new risks in accordance with Federal standards. (This is a new recommendation.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement periodic access reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from last year.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from last year.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from last year.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement two-factor authentication for remote access throughout the agency. (This is a repeat recommendation from last year.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop and implement policies and procedures for restricting privileged remote access from foreign countries that may pose a significant security risk to VA systems. (This is a new recommendation.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and Web application servers. (This is a repeat recommendation from last year.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement a patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s Web applications, database platforms, network infrastructure, and work stations. (This is a modified repeat recommendation from last year.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement standard security configuration baselines for all VA operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement procedures to enforce a system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from last year.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement processes to ensure information system contingency plans are updated with the required information and lessons learned are communicated to senior management. (This is a repeat recommendation from last year.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite. (This is a new recommendation.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology ensure that agreements for alternate processing sites have been established that define the roles and responsibilities for alternate locations in the event of a disaster. (This is a new recommendation.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology review change management procedures to ensure that any changes to system procedures are appropriately tested, validated, documented and approved. (This is a repeat recommendation from last year.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology fully implement an automated 24-hour security event and incident correlation solution to monitor security for all systems interconnections, database security events, and mission-critical platforms supporting VA programs and operations. (This is a repeat recommendation from last year.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology identify all external network interconnections and ensure appropriate Interconnection Security Agreements and Memoranda of Understanding are in place to govern them. (This is a repeat recommendation from last year.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a repeat recommendation from last year.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology provide the OIG with timely and formal notifications of network intrusions and system compromises in accordance with FISMA. (This is a new recommendation.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop a listing of approved software and implement continuous monitoring processes to identify and prevent the use of unauthorized application software, hardware and system configurations on its networks. (This is a modified repeat recommendation from last year.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a modified repeat recommendation from last year.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Acting Assistant Secretary for Information and Technology develop procedures to integrate information security costs into the capital planning process while ensuring traceability of Plans of Action and Milestones remediation costs to appropriate capital planning budget documents. (This is a repeat recommendation from last year.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement procedures for overseeing contractor-managed cloud-based systems, ensuring OIG access to those systems, and ensuring information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from last year.)
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms for updating the Federal Information Security Management Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from last year.)
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure all users with VA network access participate in and complete required VA-sponsored security awareness training. (This is a repeat recommendation from last year.)
Review of Alleged Mismanagement of VBA's Eastern Area Fiduciary Hub
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13-03018-159

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/28/2014
We recommended the Under Secretary for Benefits require the Eastern Area Fiduciary Hub to implement controls to monitor misuse determinations to ensure reviews meet timeliness standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/1/2015
We recommended the Under Secretary for Benefits require the Director of Pension and Fiduciary Service to implement controls to monitor negligence reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/1/2015
We recommended the Under Secretary for Benefits implement controls to ensure the reissuance of misused funds to beneficiaries and repayment from former fiduciaries occurs timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2014
We recommended the Under Secretary for Benefits require the Director of Pension and Fiduciary Services to conduct a negligence review of the 12 identified cases of misuse of beneficiary funds and determine if misused funds are required to be reissued to affected beneficiaries.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2018
We recommended the Under Secretary for Benefits ensures the Eastern Area Fiduciary Hub implements a plan to expedite completion of their backlog of field examinations to meet performance standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/15/2015
We recommended the Under Secretary for Benefits require the Director of the Indianapolis VA Regional Office to implement a plan to ensure the Eastern Area Fiduciary Hub eliminates its backlog of Fiduciary Program mail during FY 2014.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 944,000.00
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System
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14-02603-178

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No. 1
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary take immediate action to review and provide appropriate health care to the 1,700 veterans we identified as not being on any existing wait list.
No. 2
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary review all existing wait lists at the Phoenix Health Care System to identify veterans who may be at greatest risk because of a delay in the delivery of health care (for example, those veterans who would be new patients to a specialty clinic) and provide the appropriate medical care.
No. 3
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary initiate a nationwide review of veterans on wait lists to ensure that veterans are seen in an appropriate time, given their clinical condition.
No. 4
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 8/26/2014
We recommend the VA Secretary direct the Health Eligibility Center to run a nationwide New Enrollee Appointment Request report by facility of all newly enrolled veterans and direct facility leadership to ensure all veterans have received appropriate care or are shown on the facility's electronic waiting list.
Combined Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan
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14-00686-166

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2014
We recommended that nursing managers fully implement the plan approved in March 2014.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2014
We recommended that the annual staffing plan reassessment process ensures that the acute care unit-based expert panel includes all required members.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document the risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2017
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that wound care specialist consults are initiated and completed for all patients with pressure ulcers and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to residents' care plans and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2015
We recommended that processes be strengthened to ensure that staff document residents' progress toward restorative nursing goals and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that processes be strengthened to ensure that staff document residents' restorative progress bi-weekly and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2014
We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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14-00242-160

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2014
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2014
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that staff provide medication counseling/education as required.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Aleda E. Lutz VA Medical Center, Saginaw, Michigan
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14-00231-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Canandaigua VA Medical Center, Canandaigua, New York
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14-00244-147

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
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