All Reports

Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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13-00277-134

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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 consistently reported to the Medical Executive Board.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that processes be strengthened to ensure that continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that the facility is well maintained and that compliance be monitored and that damaged furniture in patient care areas be repaired or removed from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated correctly when opened.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that patient privacy is maintained in the PM&R clinic during potentially exposing treatment modalities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that the annual staffing plan reassessment process ensures that all required staff are facility and unit-based expert panel members.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities
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11-02585-129

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2013
We recommended that the Under Secretary for Health ensure that VHA program officials provide additional guidance on what constitutes disruptive behavior and establish common terminology.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2015
We recommended that the Under Secretary for Health ensure that VHA program officials develop guidelines for what information VHA facilities should document regarding disruptive incidents and where this information should be documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2013
We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/24/2013
We recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2013
We recommended that the Under Secretary for Health ensure that VHA facilities implement procedures to ensure more timely assignment of Category I PRFs.
Review of Alleged Transmission of Sensitive VA Data Over Internet Connections
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12-02802-111

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No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommend the Assistant Secretary for Information and Technology require that OIT personnel complete specialized training emphasizing the importance of encrypting sensitive VA data transmitted across public Internet connections.
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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12-04604-127

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that the Medical Emergency Committee collects data that measures performance in responding to resuscitation events and that code reviews include screening for clinical issues prior to codes that may have contributed to the occurrence of the codes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that the quality control policy for scanning includes the linking of scanned documents to the correct EHR and that processes be strengthened to ensure that the review of EHR quality includes all services and that EHR quality review reports are analyzed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that processes be strengthened to ensure that actions taken when data analyses indicate problems or opportunities for improvement are evaluated for effectiveness in Geriatric and Extended Care Performance Improvement Council data and the Patient Flow Coordination Collaborative.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that facility managers correct the identified cleanliness and environmental safety issues and that the EOC Committee documents progress in EOC Committee minutes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2014
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and discarded when expired.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2014
We recommended that managers initiate actions to address the identified physical security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is reconciled and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that the CS Coordinator's duties be included in his or her position description.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that all CS inspectors are appointed in writing by the facility Director prior to assuming their duties.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS include all required elements and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated physician and administrative support person.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2013
We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the Computerized Patient Record System.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that patients are re-evaluated for home oxygen therapy annually after the first year.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that the annual staffing plan reassessment process ensures that all required staff are members of the unit-based and facility expert panels.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the facility complete the staffing methodology process.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that the facility establish a construction safety program with a multidisciplinary committee that effectively monitors infection control, safety, and security issues during construction and renovation activities in accordance with VHA requirements.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that all identified infection control, safety, and security deficiencies for the Building 7 construction project be corrected and that compliance be monitored. VA
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York
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12-04191-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
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: 2/26/2014
We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to non-ICU 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: 12/11/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure IC Committee minutes reflect follow-up on actions that were implemented to address identified problems.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that KT clinic staff consistently change linens and clean equipment between patient use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that the stained privacy curtains in the KT clinic be replaced and that privacy curtains be routinely inspected and replaced as needed.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that processes be strengthened to ensure that medications in the PT clinic are secured at all times.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that the facility expert panel review unit 34's and CLC unit 3's expert panels' recommendations.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that IC staff conduct contractor TB risk assessments prior to construction project initiation.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that processes be strengthened to ensure that contractor TB skin test results are documented.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Combined Assessment Program Review of the Hampton VA Medical Center, Hampton, Virginia
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12-03077-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2013
We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2013
We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up at least weekly during the first 30 days after discharge and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2013
We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2013
We recommended that processes be strengthened to ensure that interdisciplinary teams develop treatment plans for all polytrauma outpatients who need interdisciplinary care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2013
We recommended that minimum polytrauma staffing levels be maintained.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2013
We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Community Based Outpatient Clinic Reviews at William S. Middleton Memorial Veterans Hospital, Madison, WI
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12-03854-115

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2013
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: 5/31/2013
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: 5/31/2013
We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Healthcare Inspection – Issues at a VA Mid South Healthcare Network Dental Clinic
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12-03753-121

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2013
We recommend that the System Director ensure that dental clinic staff have adequate knowledge regarding periodontal disease.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2013
We recommend that the System Director ensure treatment plans are developed, revised, followed, and documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2013
We recommend that the System Director develop and implement a plan to improve communication and professional interaction among dental clinic staff.
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.
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