All Reports

Healthcare Inspection – Quality of Care Issues, San Juan VA Medical Center, San Juan, Puerto Rico
|
13-01956-37

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2014
We recommended that the System Director ensures that thorough nutritionalassessments are completed (including weights), plans are implemented, and patient progress is continually monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2014
We recommended that the System Director ensures that processes be strengthenedto ensure that nursing staff perform and document accurate daily skin inspections for all hospitalized patients identified as being at risk for pressure ulcers, and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2014
We recommended that the System Director implement measures to ensure thatdischarge planning processes are appropriate for the patient’s condition, discharge orders comply with local policy, and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2014
We recommended that the System Director implement measures to ensure that theinformed consent process complies with VHA requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2014
We recommended that the System Director consult with Regional Counsel regardingpossible disclosure to the patient and family of failure to diagnose urinary tract infection with sepsis, and failure to prevent and treat pressure ulcers.
Healthcare Inspection – Emergency Department Length of Stay and Call Center Wait Times, VA Eastern Colorado Health Care System, Denver, Colorado
|
13-03862-35

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that the Veterans Integrated Service Network and Facility Directors ensure processes be strengthened to improve Health Information Call Center practices and staffing levels.
Audit of VA's Pharmacy Reengineering Software Development Project
|
12-04536-308

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure all of the time needed to develop and deploy each remaining Pharmacy Reengineering increment, to include the initial operating capability phase, is reported and monitored on the Project Management Accountability System Dashboard.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/18/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, develop guidance and a reliable methodology for capturing and reporting planned and actual project costs at the increment level on the Project Management Accountability System Dashboard for the remaining increments of Pharmacy Reengineering software development.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish guidance on replanning software development projects that have been paused in sufficient detail to demonstrate that increments of the projects are well thought out and achievable.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/29/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish controls to ensure information technology projects have sufficient leadership and staff assigned throughout the project life cycle.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/18/2014
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish plans on how future Pharmacy Reengineering development will be funded until a decision is made regarding transferring this effort to the Integrated Electronic Health Record project.
Alleged Chemotherapy Delay and Excessive Emergency Department Length of Stay
|
13-00488-26

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that the Facility Director ensure that length of stay in the emergency department is reviewed, and that action plans are developed to address excessive length of stay, and that action plans are implemented and monitored for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that the Facility Director ensure that the Patient Flow Committee meets as required by local policy, reviews membership to ensure inclusion of frontline staff, that follow-up reports are submitted, and that identified improvement processes are monitored and communicated to all involved staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that the Facility Director ensure that action plans addressing the monitoring and handoff communication of oncology clinic patients waiting for after-hours admission are communicated to involved staff, implemented, and monitored for compliance.
Community Based Outpatient Clinic Reviews at James H. Quillen VA Medical Center, Mountain Home, TN
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13-00026-24

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2014
We recommended that managers ensure that patients are notified of cervical cancer screening results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
We recommended that fire extinguisher signage is installed at the Morristown CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2014
We recommended that the facility ensures the exam tables are positioned so that patient privacy is respected at the Rogersville CBOC.
Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, Arizona
|
13-02642-21

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that processes be strengthened to ensure that the results of FPPEs for newly hired licensed independent practitioners are reported to the MEB.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2015
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed for all services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that processes be strengthened to ensure that the EHR copy and paste function is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the facility implement a quality control policy for scanning.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2014
We recommended that processes be strengthened to ensure that all expired medications are removed from patient care areas.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that processes be strengthened to ensure that lower storage shelves in the distribution storage area are solid and at least 8 inches above the floor.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that processes be strengthened to ensure that distribution storage area humidity and temperatures are maintained within acceptable levels and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that facility policy be amended to include that the CS Coordinator and inspectors must be free from conflicts of interest and that the CS Coordinator must have a complete understanding of CS policies and the VHA CS inspection process and to include the requirements for new CS inspector orientation and annual training thereafter.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2014
We recommended that managers initiate actions to address the two identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2015
We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly, that inspections are randomly scheduled and completed on the day initiated, and that inspectors verify hard copy orders for five dispensing activities and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2015
We recommended that processes be strengthened to ensure that the main pharmacy vault and pharmacy emergency cache are inspected monthly and that inspections include all required elements and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2014
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2014
We recommended that facility policy be amended to include that a minimum 0.25 FTE MH professional and an administrative support person be assigned to the PCCT.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2015
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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2015
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers receive dressing supplies prior to being discharged and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2015
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. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in August 2013.
Combined Assessment Program Review of the James H. Quillen VA Medical Center, Mountain Home, Tennessee
|
13-02643-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that processes be strengthened to ensure that Special Care Committee code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the cardiopulmonary event.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that the identified environmental safety hazards on the locked MH unit related to equipment, furniture, and anchor points be corrected and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that processes be strengthened to ensure that all panic alarms on the locked MH unit are tested and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization receive annual competency assessments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
We recommended that processes be strengthened to ensure that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2014
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.
Community Based Outpatient Clinic Reviews at Kansas City VA Medical Center, Kansas City, MO
|
13-00026-10

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that managers ensure that clinicians administer tetanus vaccines when indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that the medical staff’s Executive Committee grants privileges consistent with the services provided at the Belton, Excelsior Springs, and Louisburg-Paola CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2014
We recommended that handicap parking spaces, as required by the ADA, are added at the Louisburg-Paola CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2014
We recommended that the restrooms meet the ADA requirements at the Belton CBOC.
Healthcare Inspection – Alleged Improper Opioid Prescription Renewal Practices, San Francisco VA Medical Center, San Francisco, California
|
13-00133-12

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2014
We recommended that the Facility Director ensure providers comply with all elements of the management of chronic pain patients on opioid therapy, as required by VHA and the VA/DoD Clinical Guideline.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2014
We recommended that the Facility Director ensures that the Narcotic Instructions Note is reevaluated for appropriate use in the clinic and that providers comply with established protocol.
Community Based Outpatient Clinic Reviews at Richard L. Roudebush VA Medical Center, Indianapolis, IN
|
13-00026-08

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2014
We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2014
We recommended that handicap parking spaces meet ADA requirements at the Terre Haute CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and that all identified issues are tracked, trended, and corrected at the Terre Haute CBOC.
Community Based Outpatient Clinic Reviews at VA Greater Los Angeles Healthcare System, Los Angeles, CA
|
13-00026-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that the Antelope Valley CBOC IT closet is maintained according to IT security standards.
Combined Assessment Program Review of the VA Greater Los Angeles Healthcare System, Los Angeles, California
|
13-02640-06

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC and that quarterly PRC summary reports are consistently presented to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the Professional Standards Board.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the local observation bed policy be revised to include that each observation patient must have a focused goal for the period of observation and that each admission must have a limited severity of illness.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Cardiac Arrest Committee reviews each code episode.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the MRC provide oversight and coordination of the review of the quality of entries in EHRs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility continue the recently implemented process for scanning the results of non-VA purchased care into EHRs and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that representatives from Surgery and Anesthesia Services consistently attend Blood Usage Committee meetings and that the results of proficiency testing and inspections by government and private entities are routinely reported to the Blood Usage Committee.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in the Inpatient Operations Council, MEC, and MRC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that ventilation system covers are clean, housekeeping closets and soiled utility rooms are locked, and emergency call system cords are functional and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair the laminate and floor in hemodialysis to ensure infection prevention and safety standards are maintained.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SPS sterile storage area humidity is maintained within acceptable levels and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility policy be amended to include elements required by VHA policy related to physical counts of automated dispensing units, quarterly trend reports, and pharmacy drug destruction.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate actions to address identified security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are addressed and corrected.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors perform weekly inventory verifications of automated dispensing machines and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that quarterly trend reports are completed and provided to the facility Director.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all CS inspectors have current CS Drug-Diversion Inspection Certification and that inspectors receive annual updates and/or refresher training and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inspectors do not exceed the 3-year term limit and are given a 1-year hiatus before being reappointed and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all pharmacy areas, including the emergency drug cache, are inspected monthly and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inspectors perform drug destruction and audit trail verification and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Director consider consulting with Pharmacy Benefits Management to ensure the facility’s CS inspection program complies with VHA policy.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and/or risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the nurse manager reassess the target nursing hours per patient day for unit 213-2 to more accurately plan for staffing and evaluate the actual staffing provided.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated employees complete annual N95 respirator fit testing and that compliance be monitored.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all employees who work on locked MH units complete annual environmental hazards training and that compliance be monitored.
Combined Assessment Program Review of the Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio
|
13-02638-01

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2013
We recommended that processes be strengthened to ensure that sterile supply storage and soiled utility areas are secured at all times.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that the facility develop instructions for inspections of automated dispensing machines.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that processes be strengthened to ensure that quarterly trend reports include problematic trends and potential areas for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that processes be strengthened to ensure that CS inspectors receive annual CS updates and/or refresher training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2014
We recommended that processes be strengthened to ensure that CS inspectors consistently verify the number of prescription pads and that compliance be monitored.
Community Based Outpatient Clinic Reviews at VA Western New York Healthcare System, Buffalo, NY
|
13-00026-352

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2014
We recommended that the Executive Committee of the Medical Staff grants privileges consistent with the services provided at the Lackawanna and Niagara Falls CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that laboratory specimens are secured during transport from the Lackawanna and Niagara Falls CBOCs to the parent facility to prevent the disclosure of patients PII.
Healthcare Inspection – Emergency Department Patient Deaths’ Memphis VAMC, Memphis, Tennessee
|
13-00505-348

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that Facility Director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/22/2014
We recommended that the Facility Director ensure that root cause analysis action plans are documented, monitored, and completed promptly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the Facility Director ensure that patients are appropriately monitored in all emergency department rooms.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the Facility Director ensure that unit-specific competency assessments are completed for emergency department nursing staff.
Review of VA's Management of Health Care Center Leases
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12-04046-307

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, establish adequate guidance for the procurement oflarge-scale build-to-lease facilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, provide realistic and justifiable timelines for award,construction, and activation of the Health Care Center leases.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, ensure supporting analyses and key decisions regarding theHealth Care Center leases are supported and documented.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, establish central cost tracking to ensure transparency andaccurate reporting on Health Care Center expenditures.
Evaluation of VHA Community Based Outpatient Clinics Fiscal Year 2012
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13-00090-346

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
Ensure that CBOC clinicians document foot care education provided to diabetic patients in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians perform risk assessments and document risk levels for diabetic patients in the electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians document referrals for preventative foot care, including foot wear, as clinically indicated, for patients with diabetes in the electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to consistently link breast imaging and mammography results to the appropriate radiology mammogram or breast study order for all fee basis and contract patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to notify patients of normal mammogram results within the allotted timeframe and that notification is documented in the electronic health record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for privileging or re-privileging CBOC providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that facility Directors grant privileges consistent with the services provided at the CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that adequate resources and controls are in place to address deficiencies in the invoice validation process and to reduce the risk of overpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that the oversight of the contract acquisition process is compliant with VA Directives, including a thorough pre-award review and interim contract authority prior to contract approval.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that all new CBOCs undergo the required contract approval processes prior to initiating operations.
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