All Reports

Combined Assessment Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan
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14-02069-268

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that auditory privacy is maintained in all intake areas, that managers stress to staff that sensitive patient information should not be discussed in public areas, and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that all designated eye clinic employees receive eye laser safety training with the frequency required by local policy and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that processes be strengthened to ensure that clinicians document patient/caregiver understanding of discharge instructions and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that staff modify restorative nursing interventions as needed and document the modifications and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that staff document the reasons for not providing restorative nursing services when those services are care planned and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that hand-off communication occurs between Physical Medicine and Rehabilitation Service and the community living center when residents are discharged from therapy to ensure that restorative nursing services occur.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on range of motion and resident transfers.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2015
We recommended that processes be strengthened to ensure that staff document residents' restorative progress weekly and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff and Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Healthcare Inspection – Emergency Department Staffing and Patient Safety Issues, VA San Diego Healthcare System, San Diego, California
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14-00271-265

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that the System Director implement a policy that includes a plan for additional registered nurses, providers, and support staff to augment the Emergency Department in times of acute overload or disaster.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended that the System Director review the orientation processes for registered nurses floating to the Emergency Department to ensure that the orientation provided is adequate and documented consistently.
Combined Assessment Program Review of the Providence VA Medical Center, Providence, Rhode Island
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14-02066-266

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that processes be strengthened to ensure that completed actions from peer reviews are reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that processes be strengthened to ensure that the Special Care Committee collects data that measures performance in responding to codes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that the Surgical Service Staff Committee meet monthly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee meets at least quarterly and that the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2015
We recommended that processes be strengthened to ensure that when data analysis indicates problems or opportunities for improvement, actions are consistently identified, implemented, and followed to resolution in surgical performance improvement activities, electronic health record quality reviews, and blood/transfusion reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2015
We recommended that processes be strengthened to ensure that all patient care areas and public restrooms are clean and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2015
We recommended that processes be strengthened to ensure that procedures for terminal cleaning of patient rooms are followed and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that processes be strengthened to ensure that in patient care areas, damaged furniture is repaired or removed from service and damaged surfaces are repaired and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that the pharmacy clean room for compounding sterile products be brought into compliance with United States Pharmacopeia 797> cleanliness, sterility, and monitoring standards.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2015
We recommended that processes be strengthened to ensure that all required members of the Environment of Care Committee consistently attend committee meetings, that the program be strengthened to ensure effective surveillance activities, and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2015
We recommended that processes be strengthened to ensure that VA Police update the facility’s Security Management Plan annually and submit quarterly security reports to the Environment of Care Committee.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2015
We recommended that processes be strengthened to ensure that clinician assessment of patients presenting with stroke symptoms includes facility required PTT and PT/INR tests and that compliance be monitored.
Combined Assessment Program Review of the Grand Junction VA Medical Center, Grand Junction, Colorado
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14-02068-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility’s providers for teledermatology services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Anesthesia Service consistently attends meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nurse call systems be installed in the emergency department.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and expired medications are promptly removed from patient care areas and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, 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 clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that stroke guidelines be posted in the emergency department, on the critical care unit, and on all inpatient units.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Restorative Care Coordinator documents patient restorative program goals and progress weekly in accordance with facility policy and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and documented in patients’ electronic health records and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and placed in patients’ electronic health records, that any contraindications are identified and resolution documented prior to the scan, that Level 2 personnel conducting the secondary screenings sign the forms prior to the scan, and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement processes to monitor compliance with colorectal cancer timeliness and patient notification requirements.
Combined Assessment Program Review of the Bay Pines VA Healthcare System, Bay Pines, Florida
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14-01292-258

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2015
We recommended that processes be strengthened to ensure that the review of electronic health record quality includes most services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Surgery Service consistently attends meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure that oxygen tanks on the 3C surgical, 5B medical, and the 4A telemetry units are stored in a manner that distinguishes between empty and full tanks and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure that soiled utility rooms on the 5A medical, east and central community living center, and medical and surgical intensive care units are locked and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that processes be strengthened to ensure that community living center doors are secured after hours and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure crash carts inspections on the dialysis and locked mental health units include the defibrillators and are documented and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2014
We recommended that processes be strengthened to ensure that all designated same day surgery and post-anesthesia care unit employees receive bloodborne pathogens training annually and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2014
We recommended that processes be strengthened to ensure that all designated eye clinic employees receive eye laser safety training every 2 years and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure that clinicians identify post-discharge needs and include them in discharge planning.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that processes be strengthened to ensure that clinicians provide individualized, patient-specific discharge instructions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2014
We recommended that stroke guidelines be posted on the medical intensive care; 5B medical; and east, central, and west CLC units.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2015
We recommended that the facility report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure that staff consistently complete and document restorative nursing services according to clinician orders and/or residents¿ care plans and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2015
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Healthcare Inspection - Follow-up Review of the Pause in Providing Inpatient Care VA Northern Indiana Healthcare System, Fort Wayne, Indiana
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13-00670-262

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that the Veterans Integrated Service Network Director ensure continued monitoring and implementation of actions for the reopening of the Intensive Care Unit.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that the Veterans Integrated Service Network Director ensure that efforts continue to recruit qualified clinical staff to provide care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that the VA Northern Indiana Healthcare System Director ensure that efforts continue to recruit qualified staff for vacant leadership positions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2015
We recommended that the VA Northern Indiana Healthcare System Director ensure that nursing leaders assess the utilization of the nursing staff to systemically plan assignments during times when the acute medical unit¿s census is low.
Audit of VBA's Efforts to Effectively Obtain Veterans' Service Treatment Records
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14-00657-261

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/10/2018
We recommended the Under Secretary for Benefits improve monitoring to ensure Veterans Affairs Regional Office staff establish claims in the Veteran Benefits Administration’s data systems within 7 days of receipt.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/10/2018
We recommended the Under Secretary for Benefits develop a timeliness standard for Veterans Affairs Regional Office staff making initial requests for service treatment records.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/4/2015
We recommended the Under Secretary for Benefits expand access to the Veterans Information Solution to all Veterans Affairs Regional Office staff who have the responsibility of requesting service treatment records for National Guard and Reserve veterans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2016
We recommended the Under Secretary for Benefits complete testing of the National Guard and Reserve pilot program and consider nationwide implementation based on results of the testing.
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System
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14-02603-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2016
We recommended the VA Secretary direct the Veterans Health Administration to review the cases identified in this report to determine the appropriate response to possible patient injury and allegations of poor quality of care. For patients who suffered adverse outcomes, Phoenix VA Health Care System should confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2015
We recommended the VA Secretary require the Phoenix VA Health Care System to ensure continuity of mental health care, improve delays in assignments to a dedicated provider, and expand access to psychotherapy services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2015
We recommended the VA Secretary require the Phoenix VA Health Care System to reevaluate and make the appropriate changes to its method of providing veterans primary care to ensure they provide veterans timely and quality access to care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2014
We recommended the VA Secretary direct the Veterans Health Administration to establish a process that requires facility directors to notify, through their chain of command, the Under Secretary of Health when their facility cannot meet access or quality of care standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2014
We recommended the VA Secretary review all existing wait lists at the Phoenix VA Health Care System to identify veterans who may be at risk because of a delay in the delivery of health care and provide the appropriate medical care. We provided this recommendation to the former VA Secretary in the Interim Report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2015
We recommended the VA Secretary take immediate action to ensure the Phoenix VA Health Care System reviews and provides appropriate health care to all veterans identified as being on unofficial wait lists. We provided this recommendation to the former VA Secretary in the Interim Report.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2015
We recommended the VA Secretary ensure all new enrollees seeking care atthe Phoenix VA Health Care System receive an appointment within the time frames directed by VHA policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2015
We recommended the VA Secretary ensure the Phoenix VA Health Care System timely process enrollment applications.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended the VA Secretary ensure the Phoenix VA Health Care System follows VA consultation guidance and appropriately reviews consultations prior to closing them to ensure veterans receive necessary medical care.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2015
We recommended the VA Secretary ensure the Phoenix VA Health Care System staff timely verify and record veteran deaths in Veterans Health Information Systems and Technology Architecture.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2015
We recommended the VA Secretary ensure the Phoenix VA Health Care System establish an internal mechanism to perform routine quality assurance reviews ofscheduling accuracy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2015
We recommended the VA Secretary ensure all Phoenix VA Health Care System staff with scheduling privileges satisfactorily complete the mandatory Veterans Health Administration scheduler training.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2016
We recommended that upon the completion of the investigation the VA Secretary confer with appropriate VA staff and determine whether administrative action should be taken against management officials at the Phoenix VA Health Care System and ensure that action is taken where appropriate.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2015
We recommended the VA Secretary ensure Phoenix VA Health Care System include an employee satisfaction measure and a veteran satisfaction measure in Phoenix VA Health Care System management’s performance plans and facility goals.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2015
We recommended the VA Secretary initiate a nationwide review of veterans on wait lists to ensure that veterans are seen in an appropriate time, given their clinical condition. We provided this recommendation to the former VA Secretary in the Interim Report.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2015
We recommended the VA Secretary direct the Health Eligibility Center to run a nationwide New Enrollee Appointment Request report by facility of all newly enrolled veterans and direct facility leadership to ensure all veterans have received appropriate care or are shown on the facility’s electronic wait list. We provided this recommendation to the former VA Secretary in the Interim Report.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2015
We recommended the VA Secretary establish veteran-centric goals and eliminate current goals that divert focus away from providing timely quality care to all eligible veterans.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2015
We recommended the VA Secretary take measures to ensure use of “desired date” is appropriately applied.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2016
We recommended the VA Secretary provide veterans needed care in a timely manner that minimizes the use of the electronic wait list.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2015
We recommended the VA Secretary require facilities to perform internal routine quality assurance reviews of scheduling accuracy of randomly selected appointments and schedulers.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2017
We recommended the VA Secretary initiate a process to selectively monitor calls from veterans to schedulers and then incorporate lessons learned into training or performance plans.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2015
We recommended the VA Secretary conduct a review of the Veterans Health Administration’s Ethics Program to ensure the Program’s operational effectiveness, integrity, and accountability.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended the VA Secretary initiate actions to update the Veterans Health Administration’s current electronic scheduling system and ensure milestones and costs are monitored.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2014
We recommended the VA Secretary ensure that the Veterans Health Administration establishes a mechanism to ensure data representing VA’s national performance are validated by an internal group that has direct access to the Under Secretary for Health.
Healthcare Inspection – Deficiencies in the Caregiver Support Program, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
|
14-00991-255

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the Facility Director ensure that the Caregiver Support Program's Clinical Eligibility Committee meets regularly to review and discuss the clinical eligibility of current and future participants in the program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2015
We recommended that the Facility Director ensure that Caregiver Support Program applications are processed timely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the Facility Director continue efforts to ensure currently enrolled patients are monitored and assessed as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the Facility Director ensure that adequate staffing is available to meet the minimum in-home monitoring and caregiver assessment requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2015
We recommended that the Facility Director ensure that reassessments supporting continued eligibility and stipend payments are documented, as required.
Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina
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14-02067-253

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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 the Critical Care Committee reviews each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group continue to meet monthly and document its review of required performance data elements and National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all surgical deaths with identified problems or opportunities for improvement are reviewed by the Surgical Work Group.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee representative from Surgical Service consistently attends meetings and that the blood/transfusions usage review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Environment of Care Committee minutes reflect discussion of actions taken in response to identified deficiencies and that actions are tracked to closure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility’s stroke policy be revised to address data gathering for analysis and improvement 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 clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that stroke guidelines be posted on the critical care unit and the acute inpatient unit.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that secondary patient safety screening forms are signed by the patient, family member, or caregiver and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan 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 all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training 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 construction site inspection documentation includes the time of the inspection, the team members present, and the time when corrective actions occurred.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of unsafe conditions identified during inspections and follow-up actions in response to those conditions and that minutes track actions to completion.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Fayetteville VA Medical Center, Fayetteville, North Carolina
|
14-00924-247

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2015
We recommended that managers ensure that the installed modification alarm works consistently so that staff can be notified when veterans require assistance for entry into the Hamlet CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2015
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)
Closure Date: 3/31/2015
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed Fluoroquinolones was administered, prescribed, or modified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that staff consistently provide written medication information that includes the Fluoroquinolones.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2015
We recommended that staff provide medication counseling/education as required.
Combined Assessment Program Review of the VA New York Harbor Healthcare System, New York, New York
|
14-01293-243

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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 Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each resuscitation code episode.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Review Group meet monthly and include the Chief of Staff as a member.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated same day surgery and post-anesthesia care unit employees receive bloodborne pathogens training annually and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Brooklyn campus eye clinic examination room sinks have foot controls, long-blade handles, or automatic no touch sensors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Manhattan campus eye clinic have glasses/goggles of the appropriate optical density available that are specifically marked for each type of laser and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient 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 clinicians screen patients for difficulty swallowing prior to oral intake.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that employees involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients presenting with stroke symptoms receive laboratory tests for cardiac markers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff document the reasons for discontinuing or not providing restorative nursing services and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on range of motion and resident transfers.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients¿ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Providence VA Medical Center, Providence, Rhode Island
|
14-00922-240

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2014
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Hyannis and Middletown CBOCs’ contract laboratory facilities to the parent facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers complete required training within 12 months of appointment to Patient Aligned Care Teams.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
|
14-00923-237

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Milo C. Huempfner CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the door to the examination room designated for women veterans is equipped with electronic or manual locks at the Cleveland CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 7
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.
Healthcare Inspection - Improper Closure of Non-VA Care Consults, Carl Vinson VA Medical Center, Dublin, GA
|
14-03010-251

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2015
We recommended that the VISN Director review the circumstances surrounding the batch closures and confer with appropriate VA offices to determine the need for administrative action, if any.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2015
We recommended that the Facility Director track the timeliness of NVCC appointment scheduling and promptly respond to potential delays in care.
Combined Assessment Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
|
14-01291-241

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that the Surgical Work Group consistently meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Medicine Service attends meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2015
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to residents' care plans and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2015
We recommended that processes be strengthened to ensure that staff modify restorative nursing interventions as needed and document the modifications and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2015
We recommended that process be strengthened to ensure that hand-off communication occurs between Physical Medicine and Rehabilitation Service and the community living center when residents are discharged from therapy to ensure that restorative nursing services occur.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2015
We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training for range of motion.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2015
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to magnetic resonance imaging and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2015
We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Combined Assessment Program Summary Report – Evaluation of Hospice and Palliative Care in Veterans Health Administration Facilities
|
14-00727-239

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that at least the minimum required Palliative Care Consult Team staffing is provided.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that end-of-life care training is provided to staff who work in areas where they are likely to encounter patients at the end of their lives.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bay Pines VA Healthcare System, Bay Pines, Florida
|
14-00904-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2015
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2015
We recommended that CBOC/Primary Care Clinic 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)
Closure Date: 2/17/2015
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2015
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.
Inspection of VA Regional Office Des Moines, Iowa
|
14-01501-229

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/4/2015
We recommend the Des Moines VA Regional Office Director conduct a review of the 131 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/4/2015
We recommend the Des Moines VA Regional Office Director implement a plan for an additional level of review of special monthly compensation claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/4/2015
We recommend the Des Moines VA Regional Office Director implement a plan to ensure staff follow the policy for the special operations team to process special monthly compensation decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/4/2015
We recommend the Des Moines VA Regional Office Director develop and implement a plan to ensure staff prioritize processing of benefits reductions at the expiration of due process as required.
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