All Reports

Combined Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia
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13-03653-91

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the PRC submit quarterly summary reports to the MEC and that the MEC document its discussion of the reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee reviews each code episode and collects code data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that the Surgical Work Group meet monthly and document its review of required performance data elements and National Surgical Office reports.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the quality control policy for scanning include how to annotate a scanned image to identify that it has been scanned.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that the Anesthesia Service representative attends Blood Usage Committee meetings and that the blood/transfusion usage review process includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2015
We recommended that processes be strengthened to ensure that medication carts 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: 9/2/2014
We recommended that processes be strengthened to ensure that all locked MH unit staff, MSIT members, and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, the 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: 12/8/2014
We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing documentation includes VA Police response times.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the locked MH unit¿s seclusion room door open towards the hallway and that patients in seclusion have privacy while using the bathroom.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that all members of CLC-2's unit-based expert panel receive the required training prior to the next annual staffing plan reassessment.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that the newly established interprofessional pressure ulcer committee continue to meet and that the committee provide oversight of the facility's pressure ulcer prevention program.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education to patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2014
We recommended that processes be strengthened to ensure that all employees who perform restorative nursing services receive training on and competency assessment for ROM and resident transfers.
Combined Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
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13-03623-89

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2014
We recommended that processes be strengthened to ensure that the ICU Committee reviews each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the MRC analyze all reports of EHR quality review results
No. 3
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 a member from Surgery Service attends Ancillary Testing Committee meetings, that a clinical representative from Anesthesia Service is added as an Ancillary Testing Committee member, and that the blood/transfusions usage review process includes the results of peer reviews when transfusions did not meet criteria.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
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 acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 7
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 staff provide timely restorative nursing services to residents who are candidates for those services and that compliance be monitored.
No. 8
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 staff document resident progress towards restorative nursing goals, modify interventions as needed, and document the modifications and that compliance be monitored.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Salt Lake City Health Care System, Salt Lake City, Utah
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13-03420-85

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that the main entrance door access is ADA accessible at the Roosevelt CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that gowned women veterans have access to gender-specific restrooms without entering public areas at the Roosevelt CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking alcohol above NIAAA limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2014
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that CBOC/PCC staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Orlando VA Medical Center, Orlando, Florida
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14-00224-83

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that panic alarms are tested as required and testing is documented at the Kissimmee and Orange City CBOCs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that panic alarm testing results are reported to the EOC Committee, and repairs or corrections of alarm failures are tracked to completion by the EOC Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that fire drills are performed every 12 months at the Kissimmee CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that all deficiencies identified on EOC rounds at the Kissimmee and Orange City CBOCs are reported to the EOC Committee, and actions taken are tracked to completion.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that CBOC/PCC RN Care Managers complete MI and health coaching training within 12 months of appointment to PACT.
Community Based Outpatient Clinic and Primary Care Clinic Reviews at Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri
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13-03424-74

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that panic alarm testing is documented at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2014
We recommended that fire drills are performed every 12 months at the Fort Leonard Wood and Lake of the Ozarks CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Lake of the Ozarks and Mexico CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Mexico CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that the parent facility include staff at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs in required education, training, planning, and participation in annual disaster exercises.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that the parent facility document EMP-specific training completed for the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs clinical providers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that the parent facility's EMC evaluate the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that staff consistently complete follow-up assessments for patients with a positive alcohol screen.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
We recommended that staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2015
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2014
We recommended that clinical executive/primary care leaders ensure that CBOC/PCC DWHPs maintain proficiency as required for the provision of women's health care.
Combined Assessment Program Review of the Boise VA Medical Center, Boise, Idaho
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13-04241-78

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No. 1
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 code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the Surgical Invasive Procedure Committee includes the COS as a member, monitors surgery performance improvement activities, and documents its review of surgical deaths.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2015
We recommended that processes be strengthened to ensure that the review of EHR quality includes most services.
No. 4
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 clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers 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 discharge instructions are consistent with patients¿ identified post-discharge needs and include all elements required by VHA policy and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the facility have a Veterans Health Education Coordinator and an active Veterans Health Education Committee.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended that all members of the facility expert panel 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: 8/8/2014
We recommended that processes be strengthened to ensure that SCC minutes include analysis of pressure ulcer data and that the SCC routinely reports program data to facility executive leadership.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2015
We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location and stage 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: 2/19/2015
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2014
We recommended that the facility establish ongoing staff pressure ulcer education requirements and that compliance be monitored.
No. 13
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 staff complete and document restorative nursing services according to clinician orders and/or residents¿ care plans or document reasons for discontinuing or not providing restorative nursing services and that compliance be monitored.
Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah
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13-03655-84

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and completed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on patients in acute beds and that they are completed on at least 75 percent of acute care patients.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2015
We recommended that processes be strengthened to ensure that members from Surgery and Anesthesia Services attend Blood Transfusion Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that expired medications and supplies are removed from patient care areas and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2014
We recommended that processes be strengthened to ensure that aftercare needs are identified and included in discharge planning and discharge instructions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that patients receive ordered aftercare services or supplies within the ordered/expected timeframe.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that patients' and/or caregivers' knowledge and learning abilities are assessed during the inpatient stay.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that nursing managers monitor the recently implemented staffing methodology.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon discharge and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date PU acquired for all patients with PUs 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 acute care staff provide and document PU education for patients at risk for and with PUs and/or their caregivers and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2014
We recommended that processes be strengthened to ensure that staff consistently notify the wound care team when an admitted patient has a skin risk of 14 or below.
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

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 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
|
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
|
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
|
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
|
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
|
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
|
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
|
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
|
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.
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