All Reports

Healthcare Inspection – Emergency Department Patient Deaths’ Memphis VAMC, Memphis, Tennessee
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13-00505-348

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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 Facility Director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/22/2014
We recommended that the Facility Director ensure that root cause analysis action plans are documented, monitored, and completed promptly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the Facility Director ensure that patients are appropriately monitored in all emergency department rooms.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that the Facility Director ensure that unit-specific competency assessments are completed for emergency department nursing staff.
Review of VA's Management of Health Care Center Leases
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12-04046-307

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, establish adequate guidance for the procurement oflarge-scale build-to-lease facilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, provide realistic and justifiable timelines for award,construction, and activation of the Health Care Center leases.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, ensure supporting analyses and key decisions regarding theHealth Care Center leases are supported and documented.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, establish central cost tracking to ensure transparency andaccurate reporting on Health Care Center expenditures.
Evaluation of VHA Community Based Outpatient Clinics Fiscal Year 2012
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13-00090-346

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2014
Ensure that CBOC clinicians document foot care education provided to diabetic patients in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians perform risk assessments and document risk levels for diabetic patients in the electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that CBOC clinicians document referrals for preventative foot care, including foot wear, as clinically indicated, for patients with diabetes in the electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to consistently link breast imaging and mammography results to the appropriate radiology mammogram or breast study order for all fee basis and contract patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that CBOC managers establish a process to notify patients of normal mammogram results within the allotted timeframe and that notification is documented in the electronic health record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for privileging or re-privileging CBOC providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that facility Directors grant privileges consistent with the services provided at the CBOCs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2014
Ensure that adequate resources and controls are in place to address deficiencies in the invoice validation process and to reduce the risk of overpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that the oversight of the contract acquisition process is compliant with VA Directives, including a thorough pre-award review and interim contract authority prior to contract approval.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
Ensure that all new CBOCs undergo the required contract approval processes prior to initiating operations.
Audit of Selected VHA Non-Institutional Purchased Home Care Services
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11-00330-338

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended the Under Secretary for Health ensure VA medical facilities apply standardized eligibility criteria and ensure purchased home care review processes are not improperly used to limit access to purchase home care services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended the Under Secretary for Health ensure VA medical facilities maintain waiting lists for purchased home care services and assess eligible veterans¿ unmet needs for services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended the Under Secretary for Health correct eligibility information in VA's Veterans' Health Care Benefits Overview booklet and on the Office of Geriatrics and Extended Care's Web site to be consistent with VHA policy and indicate veterans do not have to be homebound to be eligible for purchased skilled care services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2014
We recommended the Under Secretary for Health strengthen non-institutional care program oversight to monitor budgeted and expended funding for purchased home care services and ensure average daily census performance monitoring data is accurate, reliable, and transparent.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended the Under Secretary for Health implement effective performance measures for purchased home care services to ensure VA medical facilities do not improperly limit access to services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2014
We recommended the Under Secretary for Health implement management controls to ensure VA medical facilities adhere to the Veterans Health Administration's requirements related to the identification and management of ineligible and high-risk purchased home care agencies.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended the Under Secretary for Health clarify the Veterans Health Administration's purchased home care policies and provide appropriate VA medical facility staff training on the proper use of eligible purchased home care agencies, exemptions, and the monitoring of high-risk agencies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2014
We recommended the Under Secretary for Health establish effective controls and monitors to ensure providers properly document orders and fee staff properly verifies the appropriateness of the services in accordance with VA fee policies before they pay for purchased home care services.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 906,700,032.00
Review of VHA's Management of Travel, Duty Stations, Salaries and Funds in the Procurement and Logistics Office
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11-01653-300

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/30/2013
We recommend the Chief Procurement and Logistics Officer establish standard operating procedures to ensure that Procurement and Logistics Office approving officials only authorize travel upon obtaining the information needed to determine if travel is necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/24/2014
We recommend the Chief Procurement and Logistics Officer perform an annual review of all Procurement and Logistics Office employees to ensure they have correct duty station assignments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/13/2014
We recommend the Chief Procurement and Logistics Officer take action to recoup salary overpayments or pay underpayments for incorrect duty station assignments, as appropriate, in accordance with VA guidance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/24/2014
We recommend the Chief Procurement and Logistics Officer provide training annually to supervisors and financial officials regarding permitted versus restricted uses of the VA Supply Fund.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/31/2013
We recommend the Deputy Assistant Secretary, Office of Acquisition and Logistics, in coordination with the Chief Procurement and Logistics Officer, establish a formal agreement outlining their respective management responsibilities and permitted versus restricted uses of the VA Supply Fund.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,803.00
Review of VA's Separately Priced Item Purchases for Training Conferences
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13-00455-345

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/8/2014
We recommended the Assistant Secretary for Human Resources and Administration consider discontinuing the use of assisted acquisition interagency agreements with the Office of Personnel Management for planning and conducting training conferences.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/8/2014
We recommended the Assistant Secretary for Human Resources and Administration establish controls to ensure adequate visibility and oversight of separately priced items purchased through existing interagency agreements with the Office of Personnel Management, to include ensuring proposed purchases are approved in advance and determined to be for incidental items that support essential tasks developed under the interagency agreement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/8/2014
We recommended the Assistant Secretary for Human Resources and Administration ensure that VA receives and reviews invoices or receipts that support all separately priced items purchased through existing interagency agreements with the Office of Personnel Management prior to authorizing payment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/24/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction update its policy to ensure a qualified individual with appropriate training in contracting is assigned to all existing interagency agreements with the Office of Personnel Management to monitor work performed on VA’s behalf.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/1/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction request the Office of Personnel Management review all bills associated with VA’s financial management training conferences, assess the results of the Office of Personnel Management’s review, and take steps to recover service fees paid to the prime vendor as a percentage of the cost of separately priced item purchases.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/1/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction assess the Office of Personnel Management’s oversight of separately priced items purchased through the interagency agreement used to fund, plan, and conduct VA’s financial management training conferences, and take steps to recover service fees paid to the Office of Personnel Management associated with inadequate oversight.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,929,000.00
Combined Assessment Program Review of the Philadelphia VA Medical Center, Philadelphia, Pennsylvania
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13-01974-337

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the PSB.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
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: 11/4/2014
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that fire extinguisher signage be in place and operational in accordance with National Fire Protection Association Standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that all designated hemodialysis employees receive annual bloodborne pathogens training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that chemicals stored on the hemodialysis unit be secured at all times and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2013
We recommended that processes be strengthened to ensure that OR employees who perform IUS receive annual competency assessments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure monthly inspections are completed in the inpatient pharmacy, the outpatient pharmacy, and the CLC vault and for the emergency drug cache and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person and a psychologist.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that the identified environmental hazards on the locked MH unit be corrected and that processes be strengthened to ensure that all environmental hazards on the locked MH units are identified and corrected.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that processes be strengthened to ensure that all staff who work on locked inpatient MH units and MSIT members receive annual environmental hazards training.
Audit of VA's Technology Acquisition Center Contract Operations
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12-02387-343

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/8/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction ensure that contracting activities can adequately justify the use of exceptions to competition requirements in the Federal Acquisition Regulation when awarding Indefinite/Delivery Indefinite Quantity task orders.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/27/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction require contracting activities to ensure program offices adequately document that goods and services cannot be acquired as conveniently or economically from a commercial source before awarding Interagency Acquisitions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/8/2015
We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction build in steps into the Integrated Oversight Process to hold contracting officers accountable for preventing violations of Federal Acquisition Regulation competition requirements.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 108,700,000.00
Combined Assessment Program Review of the Edward Hines, Jr. VA Hospital, Hines, Illinois
|
13-02315-332

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2014
We recommended that processes be strengthened to ensure that ICC minutes reflect discussion of high-risk areas and actions implemented to address these areas.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2013
We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2014
We recommended that processes be strengthened to ensure that inspectors consistently verify the three identified required drug destruction activities and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2014
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2014
We recommended that processes be strengthened to ensure that a contractor tuberculosis risk assessment is conducted prior to construction project initiation.
Audit of NCA's Contracting Practices
|
12-00366-339

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure the Contracting Service establish procedures to ensure contracts are properly awarded according to the Federal Acquisition Regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure acquisition plans, market research, and evaluations of past performance are properly documented in the contract files.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs ensure Contracting Service establish procedures to ensure competitive procurement methods are used to the maximum extent possible.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 6/26/2014
We recommend the Under Secretary for Memorial Affairs coordinate with the Office of Acquisition, Logistics, and Management to resolve Electronic Contract Management System issues to ensure system capabilities are fully used.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 8/5/2014
We Recommend the Under Secretary for Memorial Affairs ensure Contracting Service fully implements the Integrated Oversight Process and ensure required contract reviews are conducted before awarding contracts.
Community Based Outpatient Clinic Reviews at Chalmers P. Wylie Ambulatory Care Center, Columbus, OH
|
13-00026-327

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2013
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2014
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: 9/26/2013
We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2014
We recommended that managers develop a local policy for MH emergencies that reflects the CBOC’s capability and that staff is trained in the procedural steps of the MH emergency plan.
Healthcare Inspection – Quality of Care Issues, Erie VA Medical Center, Erie, PA, and VA Pittsburgh Healthcare System, Pittsburgh, PA
|
13-01855-336

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2014
We recommended that the Veterans Integrated Service Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2014
We recommended that the Veterans Integrated Service Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible disclosure to the surviving family member(s) of the patient.
Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
|
13-02316-322

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No. 1
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 EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge and that compliance be monitored.
No. 12
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 accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, and daily monitoring for a change in condition for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that the facility establish staff pressure ulcer education requirements and that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2014
We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that all designated employees complete respirator fit testing and that compliance be monitored.
Community Based Outpatient Clinic Reviews at Sheridan VA Healthcare System, Sheridan, WY
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13-00026-316

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2014
We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that MSDS are kept current at the Casper and Riverton CBOCs and that staff is trained in accessing MSDS for hazardous chemicals in the clinical area at the Casper CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that managers ensure all exit routes are clearly identified at the Riverton CBOC.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2014
We recommended that testing of the panic alarm system is documented at the Casper and Riverton CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that the Chief of OI&T implements required measures at the Casper CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2014
We recommended that EOC deficiencies are tracked, trended, and corrected at the Casper and Riverton CBOCs.
Healthcare Inspection – Inadequate Staffing and Poor Patient Flow in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland
|
12-03887-319

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director develop action plans that address emergency department patient flow and length of stay, including specialty bed access.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director develop an emergency department staffing policy that includes a contingency plan for additional physician and nurse staffing when patient care demands exceed available staffing resources.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director ensure that data collection and the reporting process are strengthened.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommend that the Facility director ensure that a local diversion policy is developed and implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2014
We recommended that the Facility Director ensure that the patient flow committee meets regularly, membership is reviewed for appropriateness, and follow-up actions are monitored.
Review of Alleged System Duplication in VA’s Virtual Office of Acquisition Software Development Project
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12-02708-301

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/18/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction implement controls to ensure the Virtual Office of Acquisition project and all future information technology development fall within the control and oversight of the Project Management Accountability System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/8/2013
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure the Technology Acquisition Center submits a business case to the Office of Information and Technology justifying how the costs associated with duplicative system requirements and future system maintenance will be managed moving forward.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,000,000.00
Community Based Outpatient Clinic Reviews at James A. Haley Veterans' Hospital, Tampa, FL
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13-00026-314

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that clinicians administer pneumococcal vaccines when indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that clinicians document all required pneumococcal vaccine administration elements and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that fire drills be completed at the Zephyrhills CBOC as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that signage is installed at the New Port Richey and Zephyrhills CBOCs that clearly identifies fire extinguisher locations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2014
We recommended that managers ensure that patient privacy is maintained as required at the New Port Richey and Zephyrhills CBOCs.
Healthcare Inspection – An Unexpected Death in a Mental Health Treatment Program, VA New Jersey Health Care System, Lyons, New Jersey
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13-01498-318

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2014
We recommended that that the Health Care System Director ensures that the Mental Health Residential Rehabilitation Treatment Program complies with local and VHA Mental Health Residential Rehabilitation Treatment Program Safe Medication Management policy requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2014
We recommended that the Health Care System Director ensure that Mental Health Residential Rehabilitation Treatment Program documentation is individualized, timely, and includes required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2014
We recommended that the Health Care System Director ensure that Mental Health leadership provides appropriate professional support for Mental Health Residential Rehabilitation Treatment Program mid-level providers.
Audit of VBA's Veterans' Retraining Assistance Program Participation
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12-04524-321

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they must monitor VA students' attendance and grades for satisfactory academic progress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they are required to report VA students' changes in enrollment to VBA within 30 days.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits revise the certifying official handbook to state a veteran's signed statement should not be used as the only means of verifying attendance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2013
We recommend the Under Secretary for Benefits reinforce to schools participating in the Veterans Retraining Assistance Program they need to accurately report credit hours and class terms in the VA ONline Certification of Enrollment system.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2014
We recommend the Under Secretary for Benefits include language on the Interactive Voice Response scripts to warn veterans of the potential penalty for certifying false enrollment information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2014
We recommend the Under Secretary for Benefits implement a plan to monitor veterans currently enrolled at the schools that had their approval withdrawn or suspended to ensure they meet Veterans Retraining Assistance Program full-time attendance requirements and are making positive progress towards program completion.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 12,000,000.00
Healthcare Inspection – Laboratory Delays and Alleged Staff Training Issues, Memphis VA Medical Center, Memphis, Tennessee
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13-02599-311

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2014
We recommended that the Facility Director ensure that processes be strengthened to ensure that laboratory turnaround times adhere to facility and VISN 9 expectations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2014
We recommended that the Facility Director ensure that policies and processes are put in place to establish consistent and appropriate methods for data collection and analysis of laboratory turnaround times.
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