All Reports

Community Based Outpatient Clinic Reviews at Marion VA Medical Center, Marion, IL
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12-03851-117

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the parent Facility Director ensures that each CBOC is assigned a WH Liaison and that the WH Liaison collaborates with the Women Veterans Program Manager.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that the service chiefs' documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Farmington and West Plains CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that the PSB grants LIPs setting-specific privileges that are consistent with the services provided at the Farmington and West Plains CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that signage is installed at the West Plains CBOC to clearly identify the location of fire extinguishers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that fire safety inspections are conducted annually at the West Plains CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that processes are strengthened to ensure patient privacy is maintained during examination at the Farmington CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that managers ensure that AEDs are checked daily at the West Plains CBOC, as required by facility policy.
Inspection of Veterans Service Center Cheyenne, Wyoming
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12-03477-118

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2013
We recommend the Denver VA Regional Office Director develop and implement controls to ensure Cheyenne Veterans Service Center staff timely schedule routine future medical reexaminations upon receipt of electronic system-generated reminder notifications.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2013
We recommend the Denver VA Regional Office Director develop and implement a Workload Management Plan that includes claims processing cycle time goals for the Cheyenne Veterans Service Center.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2013
We recommend the Denver VA Regional Office Director reinforce controls to ensure Cheyenne Veterans Service Center managers follow the Veterans Benefits Administration's policy and Workload Management Plan for all claims pending more than 1 year.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2013
We recommend the Denver VA Regional Office Director develop and implement a plan to ensure staff prioritize Systematic Analyses of Operations and corresponding recommendations and address all required elements using thorough analysis and relevant data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2013
We recommend the Denver VA Regional Office Director develop and implement a plan to ensure Rating Veterans Service Representatives correctly address Gulf War veterans' entitlement to mental health treatment as required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2013
We recommend the Denver VA Regional Office Director develop and implement a plan to monitor the effectiveness of training to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans' entitlement to mental health treatment when denying service connection for mental disorders.
Community Based Outpatient Clinic Reviews at John J. Pershing VA Medical Center, Poplar Bluff, MO
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12-03851-102

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the parent Facility Director ensures that each CBOC is assigned a WH Liaison and that the WH Liaison collaborates with the Women Veterans Program Manager.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that the service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Farmington and West Plains CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that the PSB grants LIPs setting-specific privileges that are consistent with the services provided at the Farmington and West Plains CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that signage is installed at the West Plains CBOC to clearly identify the location of fire extinguishers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that fire safety inspections are conducted annually at the West Plains CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that processes are strengthened to ensure patient privacy is maintained during examination at the Farmington CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2013
We recommended that managers ensure that AEDs are checked daily at the West Plains CBOC, as required by facility policy.
Community Based Outpatient Clinic Reviews at Iowa City VA Health Care System, Iowa City, IA
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12-03854-114

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2013
We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the FPPE review for the Cedar Rapids CBOC providers is included in the Clinical Executive Board meeting minutes.
Community Based Outpatient Clinic Reviews at Spokane VA Medical Center, Spokane, WA
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12-03852-109

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that the parent Facility Director ensures that the WH Liaisons collaborate with the Women Veterans Program Manager.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2013
We recommended that the service chief's documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Coeur d'Alene and Wenatchee CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that fire and life safety inspections are conducted annually at the Coeur d'Alene and Wenatchee CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that the Chief of OI&T evaluates the use of the IT closet and implements required measures at the Coeur d'Alene CBOC.
Community Based Outpatient Clinic Reviews at Alaska VA Healthcare System, Anchorage, AK
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12-03852-110

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2013
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2013
We recommended that fire and life safety inspections are conducted annually at the Kenai and Mat-Su CBOCs.
Community Based Outpatient Clinic Reviews at Salem VA Medical Center, Salem, VA
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12-03850-106

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that the Credentials Committee of the Executive Board for Clinical Affairs grants privileges consistent with the services provided at the Lynchburg and Wytheville CBOCs.
Healthcare Inspection – Alleged Quality of Care Issues and Communication Lapses, Washington DC VA Medical Center, Washington, DC
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12-01556-108

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2013
We recommended that the Medical Center Director consult with Regional Counsel regarding possible institutional disclosure to the patient's family for whom quality of care concerns were identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2014
We recommended that the Medical Center Director take action to improve oversight of PA practice activities in the urology clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that the Medical Center Director conduct a peer review of the care identified in this report.
Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi
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12-04605-107

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2014
We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2013
We recommended that processes be strengthened to ensure that actions implemented to address high-risk areas are documented in Infection Control Committee minutes.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2014
We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education be documented.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that unit 4C North's expert panel and CLC unit First Floor's expert panel reassess the inpatient staffing needed following the required processes.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2013
We recommended that the annual staffing plan reassessment process ensure that the facility expert panel includes all required members.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2013
We recommended that managers initiate a protected peer review for the two identified patients and complete any recommended review actions.
Audit of NCA's Internal Gravesite Review of Headstone and Marker Placement
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12-02223-98

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/16/2013
We recommended the Under Secretary for Memorial Affairs ensure implementation of the three recommendations in the July 5, 2012, Management Advisory Memorandum.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 7/30/2013
We recommended the Under Secretary for Memorial Affairs ensure management take corrective actions regarding the additional 153 errors identified in this report, including the notification of congressional committees and contacting families when possible.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 7/29/2013
We recommended the Under Secretary for Memorial Affairs implement procedures to assess cemetery size and cemetery director responsibility to ensure adequate time and resources are available before conducting future gravesite reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 7/29/2013
We recommended the Under Secretary for Memorial Affairs implement controls, including a certification, to ensure gravesite layout maps are routinely updated, accurate, and provided to the cemeteries.
Audit of VHA's Beneficiary Travel Program
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11-00336-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
We recommend the Under Secretary for Health develop mechanisms to ensure that approved Beneficiary Travel Program reimbursement data are reconciled with payment data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2014
We recommend the Under Secretary for Health implement training necessary to ensure the Veterans Health Administration staff properly code Beneficiary Travel Program expenses entered into the Financial Management System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
We recommend the Under Secretary for Health establish procedures to mitigate the risk of making duplicate payments on approved travel reimbursements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2013
We recommend the Under Secretary for Health implement procedures to verify the accuracy of beneficiary addresses at the time of request for beneficiary travel.
Community Based Outpatient Clinic Reviews at Durham VA Medical Center, Durham, NC
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12-03850-105

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2013
We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa
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12-03745-93

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
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: 8/9/2013
We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the Medical Executive Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that processes be strengthened to ensure that conversions from observation bed status to acute admissions are consistently 30 percent or less.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that the facility ensure compliance with VHA policy requiring an intraoperative x-ray for incorrect sharp counts.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that processes be strengthened to ensure that CS quarterly trend reports are consistently provided to the facility Director.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated 0.25 FTE MH provider and that local policy be updated to reflect this requirement.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2013
We recommended that the facility establish a policy to reduce the fire hazards of smoking associated with oxygen treatment.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2013
We recommended that all members of the facility expert panel receive the required training prior to the next annual staffing plan reassessment.
Review of VBA’s Transition to a Paperless Claims Processing Environment
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11-04376-81

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/12/2013
We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology broaden the types of claims tested at additional sites to provide assurance that the range of VBA functionality and processing requirements can be met through VBMS.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/7/2013
We recommend the Under Secretary for Benefits in coordination with the Assistant Secretary for Information Technology establish a plan with milestones to resolve the system issues to ensure system testing does not adversely impact and add to the existing claims processing backlog.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/12/2013
We recommend the Under Secretary for Benefits ensure development of a detailed plan, including costs associated with the long-term scanning solution, so that transformation efforts do not adversely impact and add to the existing claims processing backlog.
Healthcare Inspection – Mid-Level Provider Oversight, George E. Wahlen VA Medical Center, Salt Lake City, UT
|
12-02476-103

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2013
We recommended that the facility Director establish an equivalent process to Focused Professional Practice Evaluations and Ongoing Professional Practice Evaluations for mid-level scope of practice reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2013
We recommended that the facility Director ensure that the mid-level Professional Standards Board forwards their recommendations for the granting of scopes of practice to the Medical Executive Committee for review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2013
We recommended that all staff in the Intensive Care Unit, including the attending physicians, receive training on adverse event reporting.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2013
We recommended that systems be strengthened to ensure that all Intensive Care Unit near misses and adverse events are reported.
Combined Assessment Program Review of the San Francisco VA Medical Center, San Francisco, California
|
12-04192-97

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that the patient safety manager be included in the Leadership Board Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that data about observation bed use be gathered.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that Emergency Medical Committee code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that processes be strengthened to ensure that only sharps are disposed of in sharps containers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that Engineering conducts and documents initial safety inspections on non-patient equipment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that a process be established to ensure that HPC consults are acted upon within the timeframe required by local policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that home oxygen program patients have active prescriptions and that patients are re-evaluated for home oxygen therapy annually after the first year.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that processes be strengthened to ensure that competency assessments are completed for all staff authorized to perform oxygen testing.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that nursing managers monitor the staffing methodology that was implemented in October 2012.
Healthcare Inspection–Appointment Scheduling and Access Patient Call Center, VA San Diego Healthcare System, San Diego, California
|
12-04108-96

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2013
We recommended that the System Director ensures that Patient Call Center agents follow policy and procedures for scheduling follow-up appointments and managing non-urgent symptomatic calls.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2013
We recommended that the System Director ensures that timeframes for the primary care teams to follow-up with patients be established.
Combined Assessment Program Review of the Oklahoma City VA Medical Center,Oklahoma City, Oklahoma
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12-04189-95

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that managers initiate actions to address the three identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that monthly inspections of automatic dispensing machines are conducted in accordance with local policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that monthly CS inspection findings summaries and quarterly trend reports are consistently provided to the facility Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that the CS Coordinator's duties be included in the position description.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected monthly and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy areas with CS are conducted and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2013
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
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