Date Issued
|
Report Number
12-01284-13
All Reports
Date Issued
|
Report Number
12-00710-85
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
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
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
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 the required intervals and that compliance be monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that processes be strengthened to ensure that employees who perform glucose POCT receive training and have competency assessed annually.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/19/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that patient care areas, public stairways, and restrooms are clean.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/19/2013
We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections are conducted, that documentation includes all required elements, and that documentation reflects when deficiencies are resolved and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that managers take immediate steps to ensure the St. Albans domiciliary is in compliance with EOC standards for cleanliness, safety, and infection prevention and that compliance be monitored.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that the St. Albans domiciliary access point CCTV is functional at all times.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that the Brooklyn MH RRTP residential environment provides privacy for veterans.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/28/2014
We recommended that processes be strengthened to ensure that discharge instructions are completed for all discharged patients and that they address medications, diet, and the initial follow-up appointment.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers or required by local policy.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 2/12/2014
We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 8/8/2013
We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that all patients in buprenorphine treatment undergo UDS with the frequency required by local policy.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/24/2014
We recommended that the facility expert panel be convened prior to the next annual staffing plan reassessment and that the panel review all the unit-based expert panels' recommendations.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 1/17/2013
We recommended that processes be strengthened to ensure that FPPEs are consistently initiated and that results are consistently reported to the PSB and documented in PSB meeting minutes.
Date Issued
|
Report Number
11-00711-74
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/20/2014
We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.
Date Issued
|
Report Number
12-04190-89
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
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 Medical Executive Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the local observation bed policy be revised to include all required elements.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that staff perform continuing stay reviews for at least 75 percent of acute care patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that the Emergency Effectiveness Committee reviews individual resuscitation events.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that the blood usage review process includes the results of proficiency testing done by the laboratory.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/14/2013
We recommended processes be strengthened to ensure that the PCCT includes a dedicated nurse and administrative support person.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that all designated staff complete respirator fit testing.
Date Issued
|
Report Number
12-03355-88
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2013
We recommend the Detroit VA Regional Office Director provide training and implement controls to ensure staff follow current Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/1/2014
We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims rating decisions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2013
We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure Veterans Service Center staff follow Veterans Benefits Administration policy on proper establishment of dates of claim.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/1/2014
We recommend the Detroit VA Regional Office Director amend the local Workload Management Plan to include specific requirements for management oversight and review to improve claims processing timeliness.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/1/2014
We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2013
We recommend the Detroit 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.
Date Issued
|
Report Number
11-04359-80
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/22/2013
We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for clinical and fee staff to properly process authorizations for fee care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/10/2013
We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for fee staff to process payments of vendor invoices timely.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/14/2013
We recommended the Director of the South Texas Veterans Health Care System ensure clinical and fee staff receive periodic training on fee care procedures.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended the Director of the South Texas Veterans Health Care System establish independent oversight mechanisms, such as periodic audits or reviews by the Compliance Officer, to ensure that newly established procedures at the South Texas Veterans Health Care System are followed to properly control and manage funds for its fee care program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/22/2013
We recommended the Director of the Veterans Integrated Service Network establish independent oversight mechanisms, such as periodic audits or reviews, to ensure that procedures for properly controlling and managing fee care program funds are followed at the South Texas Veterans Health Care System.
Date Issued
|
Report Number
12-03744-84
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/7/2013
We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Staff Executive Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/7/2013
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/3/2014
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
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
We recommended that processes be strengthened to ensure that patient care areas are clean and well maintained and clean and dirty supplies are stored separately and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/12/2014
We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service and that the facility be well maintained.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/13/2014
We recommended that processes be strengthened to ensure that damaged therapy mats in the Temple division physical therapy clinic are repaired or removed from service.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/7/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated MH provider and an administrative support person.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/19/2013
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. 11
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that managers initiate a protected peer review for the three identified patients and complete any recommended review actions.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/9/2014
We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
Date Issued
|
Report Number
12-04214-83
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/7/2013
We recommended that the Facility Director ensure that the facility develops a written SOP for emergency department patient flow and orientation is provided to all emergency department staff and on-call personnel.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/20/2014
We recommended that the Facility Director ensure that EDIS is used as required.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that the Facility Director ensure that SW services are provided in the emergency department as required.
Date Issued
|
Report Number
12-02602-79
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that PR analysis summary reports be discussed quarterly at the ECMS and that the discussion be documented in meeting minutes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the ECMS.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/7/2013
We recommended that the facility develop a local policy mandating a Cardiopulmonary Resuscitation Committee.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/7/2013
We recommended that processes be strengthened to ensure that smoking occurs in designated areas only.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that staff are able to locate MSDS for hazardous chemicals used in their areas.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/7/2013
We recommended that the annual staffing plan reassessment process ensures that each unit has a unit-based expert panel and that each panel includes members from all nursing roles.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/6/2013
We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/15/2014
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Date Issued
|
Report Number
2012-03740-HI-0422
Date Issued
|
Report Number
12-03740-75
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that the local observation bed policy be revised to include all required elements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/23/2013
We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that the quality control policy for scanning be revised to include image quality, linking of scanned documents to the correct record, and indexing the documents.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that required members from surgery and medicine attend Transfusion Committee meetings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results for all projects are documented.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 11/25/2013
We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of deficiencies and follow-up actions in response to unsafe conditions identified during inspections.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/9/2013
We recommended that processes be strengthened to ensure that Material Safety Data Sheets for chemicals used in construction sites are located within the construction areas.
Date Issued
|
Report Number
12-02089-60
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/6/2013
We recommend the Anchorage VA Regional Office Director develop and implement a plan to monitor proposed disability evaluation reduction processing actions.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/6/2013
We recommend the Anchorage VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/7/2013
We recommend the Anchorage VA Regional Office Director develop and implement a plan to assess the effectiveness of training for properly processing traumatic brain injury claims.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 6/6/2013
We recommend the Anchorage VA Regional Office Director develop and implement controls to ensure management follows the Veterans Benefits Administration's policy and workload management plan for all claims pending for more than 1 year.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 6/6/2013
We recommend the Anchorage VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations using thorough analysis.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 9/18/2013
We recommend the Anchorage 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.
Date Issued
|
Report Number
11-01827-036
Date Issued
|
Report Number
11-01827-36
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health approve a plan by the end of FY 2013 that ensures all specialty care services have productivity standards within 3 years.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health establish productivity standards for at least five specialty care services by the end of FY 2013 and ensure medical facility personnel compare physician workload against these standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/5/2013
The Office of Inspector General recommends that the Under Secretary for Health provide medical facility directors with more specific guidance on how to develop staffing plans and ensure medical facility management review them at least annually to ensure optimal efficiency.
Date Issued
|
Report Number
12-03543-73
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that the facility Director implement procedures to ensure that unit-level reviews of patient falls are patient-specific and address the specific circumstances surrounding the falls.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/13/2013
We recommended that the facility Director implement procedures to ensure that fall prevention interventions are documented in patient care plans.
Date Issued
|
Report Number
12-02352-72
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/6/2013
We recommended that the Director ensure that the recommendations included in the Administrative Investigation Board report are complied with.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/6/2013
We recommended that the Director ensure that all pharmacy staff be provided ethics training to ensure that employees report unethical behavior without fear of repercussion.
Date Issued
|
Report Number
12-03076-65
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/24/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/24/2013
We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/5/2013
We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/5/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/5/2013
We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/24/2013
We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.
Date Issued
|
Report Number
10-01937-63
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director establish controls to ensure the Providence VA Medical Center accurately certifies its Annual Certification of Accounting Records.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director terminates this contract, and if the services are still needed, recruits and hires under appropriate civil service procedures.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director require the Providence VA Medical Center Director to implement controls ensuring all fund obligations are accompanied by supporting documentation to justify the obligation as required by law.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/17/2012
We recommended the Veterans Integrated Service Network 1 Director ensure service contracts are awarded based on adequate competition or, if competition is not feasible, are supported by limited or sole-source justifications as required by Federal Acquisition Regulation.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director establishes controls to ensure appropriated funds are used only for the intended purpose of the appropriation.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/6/2013
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the Designated Education Officer to obtain and oversee annual rate changes for disbursing agreements.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/6/2013
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director charges the Chief of Facilities Management Service 25 days of annual leave because his absence was not supported by an approved written justification.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/25/2013
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director institutes a control that ensures at the point timecards are certified appropriate documentation in support of approved excused absences is in place.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/17/2012
We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the property owner to make necessary repairs to alleviate future water leaks and damage, and if not repaired, moves employees in the affected areas to a more suitable workspace.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,444.00
Date Issued
|
Report Number
12-03346-69
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/19/2014
We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
Date Issued
|
Report Number
12-03741-61
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/26/2013
We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/23/2013
We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/30/2013
We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/26/2013
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.