All Reports

Administrative Investigation, Failure to Properly Supervise, Misuse of Official Time and Resources, and Prohibited Personnel Practice, VA Center for Innovation, VA Central Office
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13-01488-86

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/24/2015
We recommend that the VA Chief of Staff ensure that VBA conducts a review of all RVSRs to ensure that any not performing the functions of their position are either properly detailed or returned to their RVSR duties.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff confer with the Office of Human Resources and Administration (OHRA) and the Office of General Counsel (OGC) to determine the appropriate administrative action, if any, to take against Mr. Bramlage.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff confer with the OHRA and OGC to determine the appropriate administrative action, if any, to take against Ms. Yeary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff confer with the OHRA and OGC to determine the appropriate administrative action, if any, to take against Ms. Mullins.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff ensure that Mr. Bramlage, Ms. Yeary, and Ms. Mullins receive appropriate refresher training in supervisory responsibilities for official travel, performance standards, and appraisals.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Moore.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/9/2015
We recommend that the VA Chief of Staff ensure that Mr. Moore is issued a bill of collection for $30,990.29 to reimburse VA for a misuse of travel funds.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/9/2015
We recommend that the VA Chief of Staff ensure that Mr. Moore's time and attendance between March and October 2012 is corrected and that he is charged the appropriate annual and sick leave for that time.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/9/2015
We recommend that the VA Chief of Staff ensure that the total amount paid to Mr. Moore for the 20 instances that he was absent without authorization be determined and that Mr. Moore is issued a bill of collection for that amount, since he cannot receive pay for the time that he was absent without authorization.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff ensure that the Information Security Officer with oversight for Mr. Moore's VA-issued equipment, to include his laptop and cellular telephone, examine that equipment to remove any unauthorized software and/or content.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/12/2015
We recommend that the VA Chief of Staff ensure that all VACI employees, to include any detailed or assigned to VACI from other organizations, receive refresher training on Federal travel regulations and VA travel policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 6/9/2015
We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take concerning the prohibited personnel practice and Mr. Moore's promotion.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 7/23/2014
We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Holly.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/23/2014
We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Buchanan.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 7/23/2014
We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Thompson.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 7/23/2014
We recommend that the VA Chief of Staff confer with OHRA and OGC to determine the appropriate administrative action, if any, to take against Mr. Carroll.
Audit of VA's Hearing Aid Services
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12-02910-80

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2014
We recommend the Under Secretary for Health develop a plan to implement productivity standards and staffing levels for audiology clinics.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/4/2014
We recommend the Principal Executive Director of Office of Acquisition, Logistics, and Construction determine the appropriate staffing levels based on workload at the Denver Acquisition and Logistics Center's repair lab to help meet the timeliness standard for repair.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/4/2014
We recommend the Principle Executive Director of Office of Acquisition, Logistics, and Construction ensure Denver Acquisition and Logistics Center management establish controls to timely track and monitor hearing aids from the date received for repair.
Combined Assessment Program Review of the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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13-03648-75

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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 processes be strengthened to ensure that members from Anesthesia and Surgery Services consistently attend Transfusion Review Committee meetings and that attendance records be available to support membership and attendance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
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.
Healthcare Inspection – Environment of Care Deficiencies in the Operating Room, VA Connecticut Healthcare System, West Haven, Connecticut
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13-03747-76

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director strengthen policies and procedures related to the operating room environment of care to be consistent with recognized industry standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director develop and implement policies and procedures to address management of infectious patients in the operating room; Heating, Ventilation, and Air Conditioning system preventive maintenance; and insect control in the operating room.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director reassess Environmental Management Services staffing needs in the operating room and assign personnel requisite to the workload on each shift.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that Environmental Management Services staff and supervisors receive training on operating room environment of care requirements, especially terminal cleaning.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director implement procedures to monitor the operating room environment of care and to address identified deficiencies.
Combined Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania
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13-03626-73

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that the PRC consistently submit quarterly summary reports to the Clinical Management Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that processes be strengthened to ensure that soiled utility rooms are secured and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that processes be strengthened to ensure that construction sites are secured when unattended and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that canteen/cafeteria employees be educated on hand hygiene requirements and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that processes be strengthened to ensure that all designated x-ray and fluoroscopy employees receive annual radiation safety training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
We recommended that processes be strengthened to ensure that automated external defibrillator checks are conducted daily and documented and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2014
We recommended that the facility establish an interprofessional pressure ulcer committee.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2015
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2014
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.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Boise VA Medical Center, Boise, Idaho
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13-04331-63

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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 CBOC/PCC 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: 6/19/2014
We recommended that CBOC/PCC staff provide education and counseling for patients with a positive alcohol screen and drinking levels above NIAAA limits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that CBOC/PCC staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that CBOC/PCC RN Care Managers receive MI interviewing and health coaching training within 12 months of appointment to PACT.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that staff provide medication counseling/education that includes the fluoroquinolone.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2015
We recommended that staff document the evaluation of each patient’s level of understanding for the medication education.
Healthcare Inspection – Alleged Lapses in Communication and Poor Quality of Care, Charlie Norwood VA Medical Center, Augusta, Georgia
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13-03178-70

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2014
We recommended that the Facility Director ensure that a process is in place to assure that patient information is shared with patients, families, and significant others in an appropriate manner that protects patient privacy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2014
We recommended that the Facility Director ensure that processes be strengthened for inventory, documentation, storage, and retrieval of patient belongings, and that compliance is monitored.
Healthcare Inspection – Alleged Patient Safety Concerns in the Operating Room, VA Maine Healthcare System, Augusta, Maine
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13-03624-58

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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 Facility Director develop and implement a master staffing plan for the operating room based on Association of Perioperative Registered Nurses recommendations to ensure adequate coverage and support for operating room staff.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that the Facility Director ensure that the Surgical Work Group and Operating Room Committee are implemented and functioning in accordance with Veterans Health Administration and local policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2015
We recommended that the Facility Director implement the recommendations made during a protected Veterans Health Administration Surgical Program review.
Combined Assessment Program Review of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
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13-04242-61

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2014
We recommended that the Operative/Invasive Procedures Committee meet monthly, include the COS as a member, and document its review of National Surgical Office reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2014
We recommended that processes be strengthened to ensure that infection prevention risk assessments prioritize risks for acquiring and transmitting infections.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2014
We recommended that processes be strengthened to ensure that orders for mammograms are entered in CPRS and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/15/2014
We recommended that processes be strengthened to ensure that clinicians screen patients for tetanus vaccinations at clinic visits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/29/2014
We recommended that processes be strengthened to ensure that clinicians document all required vaccine administration elements and that compliance be monitored.
Combined Assessment Program Review of the White River Junction VA Medical Center, White River Junction, Vermont
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13-04240-60

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
We recommended that processes be strengthened to ensure that FPPE results for newly hired licensed independent practitioners are consistently reported to the CEB.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
We recommended that the local observation bed policy be revised to include how the responsible service and provider are determined and that each observation patient must have a focused goal for the period of observation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
We recommended that the Operative and Invasive Procedure Committee meet monthly and include the Chief of Staff as a member.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
We recommended that processes be strengthened to ensure that Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
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: 7/21/2014
We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2014
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2015
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale daily and at discharge and develop interprofessional treatment plans and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer stages, risk scale scores, and wound improvement or deterioration, including wound characteristics, from the time of admission to the time of discharge.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2015
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.
Healthcare Inspection – Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
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13-00872-71

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that the VISN Director take action to ensure more permanent, stable leadership in key positions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the Facility Director ensure that morbidity outliers are discussed and analyzed, and that corrective actions are taken as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that the Facility Director ensure that residents and staff discontinue use of logbooks and utilize approved electronic methods to track and schedule surgical cases.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that the Facility Director ensure adequate staffing and processes to minimize operating room delays and meet patient care needs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that the Facility Director ensure that infection control surveillance data is analyzed and trended, and that Infection Control Sub-Council minutes include required elements and reflect preventive and corrective measures.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2014
We recommended that the Facility Director ensure compliance with VHA guidance regarding identification, reporting, and follow-up of reusable medical equipment reprocessing issues, and that Reusable Medical Equipment committee minutes reflect these and other required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that the Facility Director improve Supply Processing Services processes to ensure staff are trained and competent in relevant reusable medical equipment reprocessing activities, and that competencies, manufacturer instructions, and standard operating procedures are consistent.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the Facility Director ensure that Quality Management oversight and reporting structures are fully integrated, comprehensive, and functional.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended that the Facility Director ensure oversight and subordinate committee minutes include required elements; and reflect data analysis, conclusions, action tracking and follow-up, and outcome measurement.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that the Facility Director ensure compliance with patient safety program reporting and evaluation policies, and ensure that reportable close calls are clearly defined in local policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2015
We recommended that the Facility Director ensure compliance with VHA policies on identification and reporting of cases for peer review, including use of the Occurrence Screening package.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2015
We recommended that the Facility Director ensure the Peer Review Committee complies in a timely manner with VHA guidelines regarding discussion, analysis, tracking, and follow-up of final Peer Review Committee decisions.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Montana Health Care System, Fort Harrison, Montana
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13-03416-56

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that the side entrance door is ADA accessible at the Cut Bank CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that the restroom is ADA accessible at the Cut Bank CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2014
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period for the Cut Bank and Miles City CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that signage is installed at the Cut Bank CBOC to clearly identify the location of fire extinguishers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that signage is installed at the Cut Bank CBOC to clearly identify exits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that the IT server closets at the Cut Bank and Miles City CBOCs are maintained according to IT safety and security standards.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that computer screens are secured to eliminate viewing of PII by unauthorized individuals at the Miles City CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that managers ensure that an AED is available at the Miles City CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that the parent facility document EMP-specific training completed for the Cut Bank and Miles City CBOCs' clinical providers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2015
We recommended that the parent facility¿s EMC evaluate the Cut Bank and Miles City CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2015
We recommended that CBOC/PCC staff consistently complete follow-up assessments for patients with a positive alcohol screen.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2015
We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking levels above NIAAA limits.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2015
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2014
We recommended that CBOC/PCC staff document medication reconciliation that includes the newly prescribed fluoroquinolones in the EHR.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2014
We recommended that CBOC/PCC staff provide and document medication counseling/education that includes the fluoroquinolone.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2014
We recommended that CBOC/PCC staff document the evaluation of patient's level of understanding for the medication education.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
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13-03423-55

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that the Bogalusa VA Outpatient Clinic designates handicap-accessible parking spaces as required by the ADA.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2014
We recommended that CBOC/PCC 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: 10/14/2014
We recommended that CBOC/PCC RN Care Managers receive MI and health coaching training within 12 months of appointment to PACTs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that staff document that medication reconciliation be completed at each episode of care where the newly prescribed fluoroquinolone is administered, prescribed, or modified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that staff document the evaluation of each patient's level of understanding for the medication education provided.
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa
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13-03621-57

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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 FPPE results for newly hired licensed independent practitioners are consistently reported 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 the Code Blue Committee reviews each code episode.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that nursing managers continue to complete annual staffing plan reassessments timely.
No. 4
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, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky
|
13-03652-59

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that processes be strengthened to ensure that all surgical deaths are reviewed by the facility's Surgical Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that processes be strengthened to ensure that the critical incident tracking and notification system's recipient list is current.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that that processes be strengthened to ensure that the Transfusion and Tissue Review Committee member from Anesthesia Service consistently attends meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2014
We recommended that that processes be strengthened to ensure that the CRC meets monthly and includes physician participation.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the locked MH unit and that MH Risk Assessment and Abatement Tracking data reflect risk levels and tracking of actions to closure for all identified environmental hazards on the locked MH unit.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that processes be strengthened to ensure that access to emergency exits at the Cooper division is unrestricted and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2014
We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that processes be strengthened to ensure that all panic alarms on the locked MH unit are routinely tested and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2014
We recommended that processes be strengthened to ensure that all audiovisual equipment on the locked MH unit is properly secured.
Combined Assessment Program Review of the Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri
|
13-03650-53

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that the Chief of Staff reconsider PRC membership to ensure that sufficient experienced senior physicians are regular members.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that processes be strengthened to ensure that when conversions from observation bed status to acute admissions are over 30 percent, observation criteria and utilization are reassessed timely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that processes be strengthened to ensure that CPR Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that the OR Committee (the Surgical Work Group) meet monthly and include the Chief of Staff as a member.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that the recipient list for the automated e-mail notification for critical incidents is kept current.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly and that the review of EHR quality includes most services.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings and that the blood/transfusions usage review process includes the results of inspections by government or private (peer) entities and the results of peer reviews when transfusions did not meet criteria.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that the locked MH unit nursing station have a panic alarm system.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document risk scale scores for all patients with pressure ulcers and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales and revise prevention plans when risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that processes be strengthened to ensure that acute care staff develop interprofessional treatment plans for all hospitalized patients identified as being at risk for pressure ulcers and patients with pressure ulcers and that staff provide and document recommended interventions and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2014
We recommended that processes be strengthened to ensure that applicable consults are completed for patients at risk for and with pressure ulcers and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that staff document the reasons for discontinuing or not providing restorative nursing services when those services are care planned and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2014
We recommended that processes be strengthened to ensure that staff document resident progress using the required Restorative Weekly Note.
Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania
|
13-02641-50

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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 processes be strengthened to ensure that Environmental Management Service closets are secured at all times.
No. 2
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 ceiling tiles are promptly replaced and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2015
We recommended that processes be strengthened to ensure that contractors receive OSHA Construction Safety training prior to project initiation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2015
We recommended that processes be strengthened to ensure construction sites are secured against unauthorized access and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2014
We recommended that the cause of the pooling water outside the shower on unit 7A be fixed and the identified handicapped bathroom door on unit 7A be hung correctly and that processes be strengthened to ensure that units 7A, 8A, 8B, and 39A are clean and that compliance be monitored.
No. 6
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 monthly self-inspections are conducted on all MH RRTP units and documented and that compliance be monitored.
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 medications in resident rooms on units 7A, 8A, and 8B are secured and that compliance be monitored.
Combined Assessment Program Review of the Michael E. DeBakey VA Medical Center, Houston, Texas
|
13-03649-52

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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 the COS be appointed as the chairperson of the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the MEC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2014
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that the Operating Room Committee include the COS as a member.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2014
We recommended that processes be strengthened to ensure that the Blood Utilization Committee member from Surgery Service consistently attends meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that processes be strengthened to ensure that patient care areas and restrooms are clean and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that processes be strengthened to ensure that damaged towel dispensers, doors and doorframes, and floors and baseboards are repaired and that ongoing maintenance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff and MSIT members 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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
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: 6/18/2014
We recommended that processes be strengthened to ensure that the restorative nursing initial weekly assessment is documented and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2014
We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
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