All Reports

Combined Assessment Program Review of the VA Northern California Health Care System, Sacramento, California
|
12-03074-29

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that processes be strengthened to ensure that IC Functional Committee meeting minutes include sufficient data analysis and planning for corrective actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that processes be strengthened to ensure that all food items are labeled with expiration dates, that patient nutritional products are routinely inspected to ensure they are within their expiration dates, and that hand hygiene products are readily available.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2013
We recommended that processes be strengthened to ensure that expired medications are removed and stored separately from medications available for administration.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2013
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are developed for all polytrauma outpatients who require them.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2013
We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2013
We recommended that the facility monitor compliance with its polytrauma training requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2013
We recommended that nursing managers monitor the staffing methodology that was approved in September 2012.
Combined Assessment Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan
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12-02600-28

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that test strips are stored and glucometers are maintained in accordance with the manufacturers¿ recommendations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that staff make and document post-discharge telephone calls in accordance with local policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2013
We recommended that the locked acute MH unit have camera surveillance monitoring at all required locations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that the PR Committee is consistently notified when corrective actions are completed and that this notification is documented in the meeting minutes.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that processes be strengthened to ensure that the Medical Records Committee provides oversight and coordination of EHR quality reviews and that EHR quality reviews are consistently completed for all services, including Surgical Service.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2013
We recommended that processes be strengthened to ensure that aggregated data from resuscitation episodes is reported to the CPR Subcommittee monthly and documented in the meeting minutes.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that all required services be available to polytrauma outpatients and that minimum staffing levels be maintained.
Combined Assessment Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania
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12-01877-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that all discharged MH patients receive follow-up within 7 days of discharge and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that the facility offer MH services at least one evening per week.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that treatment plans are provided to polytrauma outpatients and/or their families.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that patient care areas and fall mats are clean.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that clean and dirty equipment are stored separately.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2012
We recommended that processes be strengthened to ensure that sensitive patient information displayed on computer screens is secured.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that final summary notes for ethics consults pertaining to active clinical cases are documented in the EHRs.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2013
We recommended that processes be strengthened to ensure that glucometers are cleaned and maintained in accordance with the manufacturer's recommendations.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2013
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri
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12-02188-15

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that the holes in the walls be repaired and that processes be strengthened to ensure that patient care areas are clean.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2012
We recommended that the DRRTP have Class K fire extinguishers available in the kitchens used by residents.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that designated employees at the John Cochran dental clinic complete initial laser safety training and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that needle safety devices are available in the Jefferson Barracks dental clinic and that use of the devices be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that DRRTP and SA RRTP managers update the policies to safely manage medications and written procedures for contraband detection to include all VHA requirements and that compliance with the updated policies and procedures be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommended that processes be strengthened to ensure that monthly DRRTP and SA RRTP self-inspections are conducted and that documentation includes all required elements and corrective actions taken when deficiencies are identified.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2013
We recommended that processes be strengthened to ensure that daily SA RRTP resident room inspections are thorough.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2012
We recommended that processes be strengthened to ensure that SA RRTP rooms occupied by female veterans are safe, private, and secure.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all non-physician employees complete the facility¿s required training program prior to assisting with or providing moderate sedation.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that informed consents are completed for all patients undergoing moderate sedation and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all patients discharged from inpatient MH receive follow-up MH appointments prior to being discharged.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2013
We recommended that the annual staffing plan reassessment process ensure that unit 6N's unit-based expert panel includes representatives from all nursing roles.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that unit 6N's nurse managers reassess the target nursing hours per patient day to more accurately plan for staffing and evaluate the actual staffing provided.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that all patients with positive TBI screening results have a comprehensive evaluation within the required timeframe.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are provided to polytrauma outpatients and/or the patients' families.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
We recommended that processes be strengthened to ensure that staff in all testing areas are aware of the location of the current electronic glucose POCT manual.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2013
We recommended that processes be strengthened to ensure that staff complete the action required in response to critical test results and document in the glucometer or EHR the name of the specific provider notified of the critical test results.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2013
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.
Audit of VA’s Office of Information Technology Strategic Human Capital Management
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11-00324-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/12/2013
We recommended that the Assistant Secretary for Information Technology establish a strategic human capital plan development process that includes Office of Information Technology's senior management, managers, and employees along with appropriate stakeholders from across VA and its administrations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop and implement a strategic human capital plan that includes roles and responsibilities; human capital goals, objectives, and strategies; performance measures; and milestones as outlined in the Human Capital Assessment and Accountability Framework.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology's strategic human capital plan is aligned with VA's missions, goals, and objectives; and integrated into the Information Technology and VA Strategic Plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/12/2013
We recommended that the Assistant Secretary for Information Technology ensure the Office of Information Technology has an adequate number of leadership and staff positions assigned to administer its strategic human capital program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop a leadership succession plan, including key actions and associated milestones for its implementation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology ensure that all information technology leadership and employee competency assessments and gap analyses are completed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology develop leadership and workforce development and hiring strategies for closing identified competency gaps.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/4/2013
We recommended that the Assistant Secretary for Information Technology maintain a current listing of contracts used by each OIT organizational element and the functions performed to identify areas where OIT uses contractors to address competency gaps.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/2/2014
We recommended that the Assistant Secretary for Information Technology institute metrics and a process to measure the effectiveness of its strategies for evaluating and improving human capital management.
Healthcare Inspection - Respiratory Care and Other Clinical Concerns, VA Northern Indiana Health Care System, Fort Wayne, IN
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11-03462-17

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2013
We recommended that the facility Acting Director ensures that facility respiratory care policies are updated, including specific guidance and expectations for ordering oxygen therapy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2013
We recommended that the facility Acting Director ensures that peer review processes comply with VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2013
We recommended that the facility Acting Director implements procedures to complete an assessment of ABG usage.
Healthcare Inspection – Delays for Outpatient Specialty Procedures, VA North Texas Health Care System, Dallas, Texas
|
12-03594-10

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2014
We recommended that the Facility Director ensure that patients receive timely vascular and cardiology care and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2013
We recommended that the Facility Director ensure that providers document review of consults in the EHR and link results to consult requests and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2013
We recommended that the Facility Director ensure that staff comply with VHA policy for scheduling outpatient appointments and that compliance is monitored.
Audit of VA’s Systems Interconnections with Research and University Affiliates
|
11-01823-294

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/15/2014
We recommend the Assistant Secretary for Information and Technology establish or update all Memoranda of Understanding and Interconnection Security Agreements needed to accurately reflect operational environments and require that research partners implement information security controls commensurate with VA's information security standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/17/2014
We recommend the Assistant Secretary for Information and Technology support the Under Secretary for Health by providing the information technology infrastructure needed to implement a centralized data governance and storage model to securely manage research information over the data life cycle.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/3/2014
We recommend the Assistant Secretary for Information and Technology direct Information Security Officers to partner with the Veterans Health Administration's Institutional Review Boards, research personnel, and research partners to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/15/2015
We recommend the Under Secretary for Health develop and implement a centralized data governance and storage model that ensures accurate inventory of all research data collected, data collection compliance with research protocols, and secure management of research information over the data life cycle.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2013
We recommend the Under Secretary for Health require the Office of Research and Development to partner with Information Security Officers to routinely conduct joint oversight and monitoring of research labs to ensure security of sensitive veterans' data, compliance of data collections with research protocols, and fulfillment of the Department's information security requirements.
Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon
|
12-02601-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2013
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2013
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that the facility implement an effective fee basis referral process to ensure patients receive diagnostic testing within the required timeframe and that compliance with the new process be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2013
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2013
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2013
We recommended that the facility establish an EHR Committee that meets VHA requirements and clearly define the responsibilities of the committee.
Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California
|
12-02189-14

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
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.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2013
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 6
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be strengthened to ensure that outpatients who need interdisciplinary care have treatment plans developed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that processes be strengthened to ensure that discharge instructions address diet and the initial follow-up appointment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and documented.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be implemented to report results of tracking and trending of inter-facility transfers to the Organizational Excellence Board and to incorporate education on inter-facility transfers into new resident orientation.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2013
We recommended that processes be strengthened to ensure that EOC deficiencies are corrected within the required timeframe and that action plans are submitted for deficiencies not corrected within the required timeframe.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2013
We recommended that facility managers conduct a comprehensive EOC inspection of the facility and take appropriate actions to correct identified general cleanliness and maintenance issues.
Healthcare Inspection - Delay in Treatment, Louis Stokes VA Medical Center, Cleveland, OH
|
12-01487-08

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2013
We recommended that the Facility Director strengthen local policies by including all VHA required elements regarding procedures for contacting patients to schedule appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2013
We recommended that the Facility Director strengthen processes for clinic scheduling and consult tracking and monitor timeliness of outpatient scheduling processes for adherence with Veterans Health Administration timeliness requirements.
Review of VA's Alleged Incomplete Installation of Encryption Software Licenses
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12-01903-04

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/11/2012
We recommended the Assistant Secretary for Information Technology complete the software encryption project assessment to determine whether to continue or terminate the project.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/5/2014
We recommended the Assistant Secretary for Information Technology, if it is determined to continue the project, develop a plan that includes sufficient human resources and monitoring to install and activate all of the purchased encryption software licenses.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,100,000.00
Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota
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12-02599-03

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2013
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2013
We recommended that minimum polytrauma staffing levels be maintained.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2013
We recommended that the facility monitor compliance with polytrauma training requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2014
We recommended that processes be strengthened to ensure that Case Managers consistently communicate with the inpatient and/or their family at the required intervals.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2013
We recommended that processes be strengthened to ensure that polytrauma patient care areas are clean and well maintained.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2013
We recommended that processes be strengthened to ensure that staff document all required elements in response to critical values on a nursing progress note or the Nursing Critical Value Template note.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2013
We recommended that nursing managers monitor the staffing methodology that was implemented in May 2012.
Audit of VBA's Liquidation Appraisal Oversight in the Cleveland and Phoenix Regional Loan Centers
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10-04045-124

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 10/4/2012
We recommended the Under Secretary for Benefits revise Loan Guaranty Service policies and procedures to include more specific criteria for evaluating appraisal comparable property selections and sales price adjustments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2013
We recommended the Under Secretary for Benefits implement an automated appraisal review system to evaluate every liquidation appraisal.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2013
We recommended the Under Secretary for Benefits fully implement all defined elements of the Loan Guaranty Service Risk Management Program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2013
We recommended the Under Secretary for Benefits revise the performance plan of the appropriate Loan Guaranty Service manager to ensure accountability for accomplishment of specific Risk Management Program requirements.
Review of Alleged Delays in VA Contractor Background Investigations
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12-00165-277

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 10/18/2013
We recommend that the Assistant Secretary for Operations, Security, and Preparedness implement improved policies, procedures, and practices to reduce the backlog of contractor background investigations and educate appropriate personnel on VA's personnel security requirements and contractor on-boarding processes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/30/2019
We recommend that the Assistant Secretary for Operations, Security, and Preparedness, in conjunction with the Assistant Secretary for Information Technology, implement a central case management system to automate the background investigation process and effectively monitor VA contractor status and associated contract costs during the background investigation process.
Administrative Investigation of the FY 2011 Human Resources Conferences in Orlando, Florida
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12-02525-291

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/30/2012
We recommended the VA Secretary take the appropriate action against Mr. Sepúlveda.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Muellerweiss and ensure that action is taken.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Deanes and ensure that action is taken.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 10/23/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Dr. McMahan and ensure that action is taken.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 10/23/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Barritt and ensure that action is taken.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/2/2014
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Dudley and ensure that action is taken.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/2/2014
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Thomas and ensure that action is taken.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Gingrich and ensure that action is taken.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 10/23/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Dr. McMahan and ensure that action is taken.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Coke and ensure that action is taken.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 8/16/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Pleso and ensure that action is taken.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. McIntosh-Moore and ensure that action is taken.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 8/16/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Wakeley and ensure that action is taken.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/2/2014
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Dudley and ensure that action is taken.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 10/23/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Barritt and ensure that action is taken.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Caruso and ensure that action is taken.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Gardner and ensure that action is taken.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/1/2013
We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Pierce and ensure that action is taken.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary establish a policy that VA will no longer solicit lodging accommodation upgrades as part of contracts.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary modify VA procedures to include a requirement for a detailed spend plan to ensure cost estimates are reasonable.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary implement policy to ensure conference managers obtain subsequent authorization from the Chief of Staff or the Deputy Secretary once they determine estimated costs have been exceeded or other major changes occur.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary require an after-action report be provided to the Chief of Staff or the Deputy Secretary identifying planned-versus-actual costs, including justifications for significant differences.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary issue policy outlining requirements for authorizing, justifying, and conducting pre-planning site visits for conferences.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary establish requirements to support major conferences with contracting officers and other support resources to ensure conferences and the supporting acquisitions are planned and managed in accordance with applicable regulations.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/21/2016
We recommended the VA Secretary establish budgetary controls to ensure centralized accounting for individual conference expenditures.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 4/21/2016
We recommended the VA Secretary ensure conference budgets are authorized and monitored to ensure appropriate expenditures.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary establish controls to ensure senior officials exercise their responsibility and accountability for prudent management of conference funds.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary require travelers and approvers to comply with the requirement to not incur hotel taxes in states which offer tax exemption to the Government.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary require conference planning committees to identify, by name, individuals needed onsite for conference support before or after the conference and that this designation be provided to the traveler for inclusion in their travel receipts.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 1/27/2015
We recommended the VA Secretary require travelers and approving officials to comply with the requirement to include a cost comparison when choosing to use a privately owned vehicle instead of a government contracted mode of transportation.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 11/5/2013
We recommended the VA Secretary develop a process to track and monitor the use of interagency agreements.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/21/2013
We recommended the VA Secretary establish a mechanism to modify existing high-risk interagency agreements and ensure that all future interagency agreements account for costs associated with each single conference event.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/3/2013
We recommended the VA Secretary establish a process to obtain detailed vendor invoice information to support tracking and validation of costs associated with interagency agreements.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary require that all VA program offices (Administrations, Boards, Centers, and Offices) that plan meetings, conferences, or events involving more than 50 staff identify and clearly state all event requirements to minimize contract modifications.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary develop a mechanism to ensure that commitments, expenditures, and combined liabilities exceeding $25,000 receive a legal and technical review.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary ensure a Price Negotiation Memorandum be used to document negotiated agreements to minimize the possibility of future claims against the Government and to obtain a clear understanding from the contractor that all costs have been fully considered.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/19/2013
We recommended the VA Secretary ensure contracting officers designate and authorize in writing a Contracting Officer's Representative on all contracts and orders other than those that are firm-fixed-price and for firm-fixed-price contracts as appropriate.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/20/2014
We recommended the VA Secretary ensure that only authorized contracting personnel make commitments or changes that affect price, quality, quantity, delivery, or other terms and conditions of a contract.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary ensure contract modifications are completed timely.
No. 40
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/20/2014
We recommended the VA Secretary establish oversight mechanisms to eliminate excessive and wasteful conference expenditures of public funds.
No. 41
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/19/2013
We recommended the VA Secretary ensure contracting officers document the results of all contract actions in VA's Electronic Contract Management System.
No. 42
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/21/2014
We recommended the VA Secretary take action to ratify any legal agreements made by VA employees where there was no previous authority to commit payments for goods and/or services with the Marriott.
No. 43
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 4/21/2016
We recommended the VA Secretary establish an effective cost system for credit card purchases that appropriately assigns costs to individual major VA events.
No. 44
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 11/5/2013
We recommended the VA Secretary ensure purchase card approvers are trained on proper oversight of purchase card transactions.
No. 45
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/19/2013
We recommended the VA Secretary ensure VA Learning University personnel with acquisition support responsibilities have valid warrants and that the warrants match their purchase authorization.
No. 46
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/21/2013
We recommended the VA Secretary issue guidance regarding the proper procedures for transferring warrants within VA organizations.
No. 47
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary ensure VA Learning University employees are trained on purchase card policies related to splitting purchases.
No. 48
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/19/2014
We recommended the VA Secretary ensure supervisors have the required documentation prior to approving purchase card transactions.
No. 49
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 8/15/2014
We recommended the VA Secretary require the Department to accomplish a special review of purchase card transactions made in support of VA Learning University conferences.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 762,198.00
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