All Reports

Review of Alleged Unauthorized Commitments Within VA
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13-00991-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Combined Assessment Program Review of the Wilmington VA Medical Center, Wilmington, Delaware
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13-04243-151

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2014
We recommended that the facility establish an interprofessional pressure ulcer committee.
No. 14
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
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14-00687-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2014
We recommended that the Surgical Work Group meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Audit of the Quick Start Program
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12-00177-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the VA Montana Health Care System, Fort Harrison, Montana
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14-00685-156

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Interim Report - VBA's Efforts to Effectively Obtain Service Treatment Records and Official Military Personnel Files
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14-00657-144

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Audit of VHA's Mobile Medical Units
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13-03213-152

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection - VA Patterns of Dispensing Take-Home Opioids and Monitoring Patients on Opioid Therapy
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14-00895-163

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Canandaigua VA Medical Center, Canandaigua, New York
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14-00688-162

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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 be strengthened to ensure that EOC Work Group minutes reflect that actions are taken in response to identified deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at James E. Van Zandt VA Medical Center, Altoona, Pennsylvania
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14-00236-153

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2013
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13-00054-148

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Summary Report - Construction Safety at Veterans Health Administration Facilities
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14-01288-145

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Audit of the Non-Recurring Maintenance Program
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13-00589-137

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida
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14-00689-142

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection - Improper Procurement and Billing Practices for Anesthesiology Services, George E. Wahlen VA Healthcare System, Salt Lake City, Utah
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13-01819-133

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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 the Under Secretary for Health develop and implement a plan of action to ensure that VA purchase of medical services from affiliated academic institutions is in compliance with VA Directive 1663 and procurement laws and regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2015
We recommended that the Under Secretary for Health ensure that VA prohibits the use of purchase orders to obtain contract provider services unless the purchase orders contain the required clauses identified in the report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2015
We recommended that the Veterans Integrated Service Network Director ensure that the procurement of specialized medical services is in accordance with VA Directive 1663.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2014
We recommended that the Veterans Integrated Service Network Director ensure that Interim Contract Authority is appropriately granted and used as outlined in VA Directive 1663.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the VA Salt Lake City Health Care System Director develop and implement as necessary an alternate source plan for the provision of anesthesiology services that complies with VA Directive 1663.
Healthcare Inspection – Alleged Excessive Wait for Emergency Care and Staff Disrespect, VA Southern Nevada Healthcare System, Las Vegas, Nevada
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14-01104-134

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2014
We recommended that the Facility Director ensure that action plans are developed and implemented to facilitate meeting and maintaining the facility's target of not more than 10 percent of emergency department patients should experience a length of stay exceeding 6 hours.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that the Facility Director ensure that nursing staff reassess emergency department patients according to facility policy.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Birmingham VA Medical Center, Birmingham, Alabama
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14-00227-131

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that 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)
We recommended that staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
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