All Reports

Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California
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13-00279-156

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that actions from peer reviews are clearly defined and consistently tracked to completion at the service level.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria are reported to the Transfusion Review Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that processes be strengthened to ensure that sharps containers in the Menlo Park CLC are readily accessible to all staff.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2013
We recommended that processes be strengthened to ensure that expired multi-dose vials are removed from medication carts in the CLC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2014
We recommended that the facility fully implement the nurse staffing methodology.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
Administrative Investigation, Misuse of Official Time and Resources and Failure to Properly Supervise, Office of Human Resources and Administration, Washington, DC
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12-02503-151

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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: 2/11/2014
We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take against [redacted] and ensure that action is taken.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/7/2017
We recommend that the Acting Assistant Secretary for Human Resources and Administration determine the total salary paid to [redacted] for the 39 days that [redacted] was AWOL from VA or worked for [redacted] while on sick leave and ensure that a bill of collection is issued to [redacted] for that amount, since [redacted] cannot receive pay for the period of time that [redacted] was absent without authorization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 2/11/2014
We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with OHR and OGC to determine the appropriate administrative action to take against Mr. Viani and ensure that action is taken.
Administrative Investigation, Improper Locality Pay, Service Area Office West and Desert Pacific Healthcare Network, Long Beach, CA
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12-01841-152

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2013
We recommend that the SAO West Director ensure that the employee's personnel records accurately reflect her duty station as San Diego from January [redacted], 2012, to present and that a bill of collection is issued to her for the total amount of improper locality pay given to her.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2013
We recommend that the SAO West Director determine whether the employee should be permitted to telework, and if so, ensure that Mr. Blanchard and the employee receive annual telework training and complete the proper telework paperwork prior to the employee engaging in any telework.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2013
We recommend that the Director of the Desert Pacific Healthcare Network ensure that [redacted] receives HR training as it relates to duty stations, locality pay, and teleworking.
Healthcare Inspection - Evaluation of Cataract Surgeries and Outcomes in VHA Facilities
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11-02487-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2013
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.
Inspection of VA Regional Office Nashville, Tennessee
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12-03629-139

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/18/2014
We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record to support scheduling of medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2014
We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure claims processing staff take accurate and timely actions to propose or finalize reductions in benefits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/7/2013
We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure accurate second signature reviews of traumatic brain injury claims decisions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/7/2013
We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers under the VA Regional Office's jurisdiction.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/18/2014
We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure staff accurately identify and expedite processing and monitoring of all homeless veterans' claims.
Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio
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13-00275-149

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
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 for Inpatient Evaluation Center data, utilization management, outcomes from resuscitation, copy and paste, and blood/transfusion reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that two transfers of CS from one storage area to another are validated and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that inspectors sign and initial inspection documents in accordance with local policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2014
We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that interdisciplinary care plans for HPC inpatients include all elements required by local policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2013
We recommended that managers initiate internal protected peer review for the three identified patients and complete any recommended review actions.
Healthcare Inspection – Excessive Length of Stay and Quality of Care Issues in the Emergency Department, William Jennings Bryan Dorn VA Medical Center, Columbia, SC
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12-03038-145

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that the Facility Director identify a reporting structure for Emergency Department Integration Software data and ensure that mandated quarterly reports containing and utilizing Emergency Department Integration Software data are provided.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended that the Facility Director ensure that planned actions to address patient flow (hire additional providers and extend hours for the non-urgent area) are implemented and that patient flow outcomes are monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2014
We recommended that the Facility Director ensure that Emergency Department providers and other clinical and administrative staff receive training on the use of Emergency Department Integration Software delay reasons and that accuracy is monitored.
Healthcare Inspection - Improper Conduct During Merit Review Proceedings
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12-02317-144

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
To ensure the integrity of the Merit Review process and the appropriateness of funding Dr. Y's research, we recommend that ORD conduct an Administrative Board of Investigation into Dr. X's actions and their consequent effects on the outcome of the review process, and to take appropriate actions, as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2013
We recommend that ORD consider making modifications to the review process such as: (a) prohibiting SRG members from attending meetings where a spouse's (or immediate family member's) proposal is scheduled for discussion; (b) not posting reviewers' identities prior to the formal SRG group discussion; (c) blinding proposals so that reviewers cannot easily identify the author; and (d) requesting SRG members specify the proposals they are competent to review, but not asking for preferences or selection of primary, secondary, or tertiary reviewer roles.
Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri
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13-00273-147

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that the Clinical Safety Committee reviews each code episode and that code reviews include screening for clinical issues prior to non-intensive care unit codes that may have contributed to the occurrence of the code.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that facility managers develop and implement a policy that details quality control for scanning into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that the Transfusion Review Committee meets quarterly and that processes be strengthened to ensure that the blood usage review process includes consistent reporting of data and the results of proficiency testing and peer reviews.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
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 for outcomes from resuscitation, EHR reviews, blood/transfusion reviews, and system redesign.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Clinical Safety Committee minutes document those actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2013
We recommended that facility managers develop and implement a policy that details cleaning of equipment between patients and that compliance with the policy be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that identified women's health-related deficiencies are tracked to closure.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that the facility implement a PCCT that complies with VHA requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that high-risk home oxygen patients receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education is documented.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that all new home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that processes be strengthened to ensure that the home oxygen vendor is notified when a patient is identified by the facility as being a high-risk smoker.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2013
We recommended that nursing managers implement all the required processes for the staffing methodology for nursing personnel.
Community Based Outpatient Clinic Reviews at San Francisco VA Medical Center, San Francisco, CA
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13-00026-137

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2013
We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2014
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2013
We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2013
We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2013
We recommended that panic alarms in high-risk areas are tested and that testing is documented.
Combined Assessment Program Review of the Battle Creek VA Medical Center, Battle Creek, Michigan
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12-04188-140

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that senior leaders routinely discuss the facility's Inpatient Evaluation Center data and ensure the discussion are documented in the minutes of a senior-level committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that the facility's local observation bed policy be revised to include all required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2013
We recommended that processes be strengthened to ensure that conversions from observation bed status to acute admissions are consistently 30 percent or less.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2014
We recommended that processes be strengthened to ensure that continued stay reviews are completed on at least 75 percent of patients in acute beds.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2013
We recommended that the quality control policy for scanning includes indexing the documents, linking scanned documents to the correct record, and image quality.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that blood/transfusion reviews are consistently completed at least quarterly.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that tables used for women's health examinations are placed with the foot facing away from the door or are shielded by privacy curtains.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2013
We recommended that the physical therapy clinic have exit signage.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that managers initiate actions to address the identified deficiency and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2013
We recommended that processes be strengthened to ensure that the PCCT includes a 0.25 full-time employee equivalent physician.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2013
We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2013
We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain the need to provide educational information on the hazards of smoking while oxygen is in use at least every 6 months after the initial delivery.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2014
We recommended that facility implement the mandated staffing methodology for nursing personnel.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2013
We recommended that managers initiate protected PR for the one identified patient and complete any recommended review actions.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2013
We recommended that processes be strengthened to ensure that designated employees receive initial and ongoing construction safety training and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that Material Safety Data Sheet information for hazardous materials is maintained within the construction area.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2013
We recommended that processes be strengthened to ensure that contract workers wear VA-issued identification badges.
Healthcare Inspection – Alleged Quality of Care and Problems with Services, VA Gulf Coast Veterans Health Care System, Biloxi, MS
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12-02612-141

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2013
We recommended that the Facility Director ensure that a quality of care review is conducted with specific attention to the deficiencies identified in this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2013
We recommended that the Facility Director strengthen processes to address patient complaints regarding the automated telephone system at the Mobile CBOC.
Combined Assessment Program Review of the Charles George VA Medical Center, Asheville, North Carolina
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13-00276-135

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2014
We recommended that processes be strengthened to ensure that actions from PRs are consistently completed and reported to the PR Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2013
We recommended that the local observation bed policy be revised to include all required elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2014
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing and of PRs when transfusions did not meet criteria.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2014
We recommended that processes be strengthened to ensure that documentation for blood product transfusions includes applicable laboratory/clinical results post-transfusion and the assessment of outcome.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
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 in utilization management, resuscitation, and blood/transfusion utilization reviews.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to housekeeping deficiencies identified during EOC rounds are tracked to closure.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Committee minutes document those actions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that expired commercial supplies are removed from sterile storage rooms and treatment areas.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that After-Installation Checklists are completed for all ceiling lifts in the PT/OT/KT clinic areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that damaged chairs in the PT/OT/KT clinic areas are repaired or removed from service.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2013
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2014
We recommended that processes be strengthened to ensure that home oxygen program patients receive a timely annual re-evaluation after the first year.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/20/2013
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Review of VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2012
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12-04241-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2013
We recommended the Under Secretary for Health implement its corrective action plan, as described in the Performance and Accountability Report, for reducing improper payments in the Non-VA Care Fee program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2013
We recommended the Under Secretary for Health develop achievable reduction targets for the Non-VA Care Fee program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2013
We recommended the Under Secretary for Health implement an improper payments estimation methodology that will achieve the required statistical precision for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2013
We recommended the Under Secretary for Benefits develop and implement a statistically valid estimation methodology for the Compensation, Pension, and Vocational Rehabilitation and Employment programs for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/13/2013
We recommended the Under Secretary for Benefits develop a process to collect and report the required improper payments recapture information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/13/2013
We recommended the Executive in Charge for the Office of Management and Chief Financial Officer complete planned activities to improve compliance with the Improper Payments Elimination and Recovery Act and use this information to develop and issue additional guidance.
Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
|
13-00277-134

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2014
We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Board.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2014
We recommended that processes be strengthened to ensure that continued stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that the facility is well maintained and that compliance be monitored and that damaged furniture in patient care areas be repaired or removed from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated correctly when opened.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that processes be strengthened to ensure that patient privacy is maintained in the PM&R clinic during potentially exposing treatment modalities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that the annual staffing plan reassessment process ensures that all required staff are facility and unit-based expert panel members.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2013
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Healthcare Inspection - Management of Disruptive Patient Behavior at VA Medical Facilities
|
11-02585-129

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

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

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

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2014
We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to non-ICU codes that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure IC Committee minutes reflect follow-up on actions that were implemented to address identified problems.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that KT clinic staff consistently change linens and clean equipment between patient use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that the stained privacy curtains in the KT clinic be replaced and that privacy curtains be routinely inspected and replaced as needed.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that processes be strengthened to ensure that medications in the PT clinic are secured at all times.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that the facility expert panel review unit 34's and CLC unit 3's expert panels' recommendations.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that IC staff conduct contractor TB risk assessments prior to construction project initiation.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2014
We recommended that processes be strengthened to ensure that contractor TB skin test results are documented.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2013
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2013
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
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