All Reports

Date Issued
|
Report Number
21-02145-243
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Topics:  VA Police

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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: 5/16/2023
Ensure the director of the Office of Operations, Security, and Preparedness creates a written policy establishing minimum standards for ballistic armor for Executive Protection Division personnel based on agents’ input, industry best practices and research, and relevant threat levels, which is routinely reassessed for adequacy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Make certain that the director of the Office of Security and Law Enforcement develops onboarding procedures for new Executive Protection Division personnel who are or may be assigned to protective details or motorcades of the VA Secretary or Deputy Secretary, including procedures for measuring personnel and procuring new ballistic vests or assessing and approving the use of an employee’s own vest to ensure it meets minimum safety standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Require the director of the Office of Security and Law Enforcement to establish procedures to track the maintenance and expiration of ballistic vests assigned to Executive Protection Division personnel and to ensure their replacement as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Instruct the director of the Office of Security and Law Enforcement to create procedures for monitoring compliance with the standard operating procedure requirement to wear ballistic armor, such as periodic inspections, and establish consequences for noncompliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
The OIG recommends that the director of the Office of Security and Law Enforcement conducts a review of the condition of all firearms currently assigned to EPD special agents and determines whether any are in need of replacement.
Date Issued
|
Report Number
22-00971-217
|
Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Implement a more effective process to maintain consistent inventory information for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Improve the vulnerability and flaw remediation program to accurately identify vulnerabilities and enforce flaw remediation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/17/2023
Implement effective configuration control processes that ensure network devices maintain vendor support.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/28/2025

Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/25/2023
Ensure installation of distributed network infrastructure equipment that meets VA installation standards, to include proper equipment mounting and clearance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Ensure routine maintenance is conducted on uninterruptible power supplies.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Implement database authentication processes that comply with VA security requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/17/2023
Implement a physical access control system for the data center and core switch room that is supportable and can meet VA logging requirements.
Date Issued
|
Report Number
21-03906-226
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Topics:  Patient Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2025

Coordinate with the Prosthetic and Sensory Aids Service executive director to (1) develop and issue guidance clearly articulating eligibility requirements for the lifetime benefit amounts to address non-service-connected disabilities and (2) communicate this guidance in an effective manner, such as including specific language in handbooks, providing examples of scenarios to reinforce the requirements, and requiring annual training to make sure all prosthetic staff responsible for the program understand these eligibility requirements.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2023
Coordinate with the Prosthetic and Sensory Aids Service executive director to make sure Veterans Integrated Service Network prosthetic representatives look at veteran eligibility for non-service-connected disability benefits in their annual reviews of medical facilities’ prosthetics programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
Coordinate with the Prosthetic and Sensory Aids Service executive director to correct and update inaccurate information on the publicly accessible Home Improvements and Structural Alterations Program website.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to make sure medical facilities or Veterans Integrated Service Networks implement procedures for verifying that veterans’ Home Improvement and Structural Alterations packages include documentation of approval and justification for all improvements and alterations paid for with program benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2024

Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to ensure medical facilities and Veterans Integrated Service Network directors implement procedures to capture when key documentation is received and monitor these dates to ensure facilities adhere to timelines for the Home Improvements and Structural Alterations Program and take corrective action when they are not meeting standards outlined in 38 C.F.R. §§ 17.3100 through 17.3130 and VHA Directive 1173.14.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,798,444.00
Date Issued
|
Report Number
21-00887-211
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Topics:  Maintenance and Construction

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The director of Veterans Integrated Service Network 2 should ensure useful life assessments are conducted for those boilers operating past their expected or extended lifespans outlined in this report to ensure safe operation. 23
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The director of the Office of Healthcare Engineering should clarify policies and procedures for scheduling useful life assessments of boilers prior to the end of expected lifespans and after an extension has been granted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The director of the Office of Healthcare Engineering should update VHA Directive 1810 to ensure that medical facility boiler policies are updated to reflect site-specific safety device testing procedures, including justifications for each test prescribed in the VHA Boiler and Associated Plant Safety Device Testing Manual that the medical facility does not plan to perform.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The director of the Office of Healthcare Engineering should update VHA Directive 1810 to clarify which tests and inspections require the use of third-party inspectors, as well as the frequency of these tests and inspections.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2023
The director of Veterans Integrated Service Network 2 should review medical facilities’ boiler operation policies to ensure procedures for notifying management and documenting corrective action plans and timelines for addressing safety incidents are consistent with VHA Directive 1810 requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The director of Veterans Integrated Service Network 2 should employ a management information system to ensure all individuals with oversight responsibility are granted access to records for boiler maintenance deficiencies and corresponding corrective actions, boiler inventory, testing and inspection compliance, and useful life assessment completeness.
Date Issued
|
Report Number
22-00815-232
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Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.

Date Issued
|
Report Number
21-02326-233
|
Topics:  Community Care ● Care Coordination ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2023
The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2023
The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2023
The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.
Date Issued
|
Report Number
22-00404-207
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Topics:  Claims and Medical Exams

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/23/2023

Implement electronic system enhancements to require claims processors to identify relevant evidence before a medical opinion request can be submitted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2023
Enhance mandated training for all claims processors on making medical opinion requests and demonstrate progress showing that the training is achieving its intended impact.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/29/2024

Strengthen monitoring controls by improving the national and local quality review processes to identify medical opinion request areas in need of improvement and demonstrate progress toward ensuring compliance with established procedures.

Date Issued
|
Report Number
22-00208-221
|
Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Require the finance office to perform quarterly compliance reviews of pharmacy invoice reconciliations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Ensure the healthcare system submits Medical/Surgical Prime Vendor–Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2023
Ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance concerns and challenges.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2023
Develop and implement a plan to increase inventory turnover to the Veterans Health Administration‑recommended level.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2023
Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,940.00
Date Issued
|
Report Number
22-00814-230
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures healthcare providers inform patients and/or caregivers when a medication is not FDA-approved; provide the option to refuse the medication; and advise them of the known risks, benefits, and alternatives prior to administration.
Date Issued
|
Report Number
21-03061-209
|
Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2023
Centralize all Camp Lejeune-related claims processing at the Louisville VA Regional Office, or implement a plan and report progress mitigating the error rate disparity between the Louisville Regional Office and other regional offices.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2023
Conduct and report to the Office of Inspector General the results of targeted quality reviews of Camp Lejeune-related claims from all regional offices processing these claims until the accuracy rate meets or exceeds the Veterans Benefits Administration’s overall national accuracy goal for disability compensation claims.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,800,000.00
Date Issued
|
Report Number
21-03595-219
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Topics:  Care Coordination ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director confirms that a process is in place to ensure community living center staff have knowledge of policies pertaining to nursing practice and documentation in the community living center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2022
The VA Greater Los Angeles Health Care System Director ensures all nursing staff assigned to the community living center have received training on the completion and documentation of all required elements for pain assessments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2022
The VA Greater Los Angeles Health Care System Director verifies that community living center nursing staff demonstrate knowledge of the procedure for managing verbal and telephone orders and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director reviews the Greater Los Angeles Healthcare System hand-off communication policy to determine if changes are warranted to address the procedure for managing hand-offs, ensures understanding of policy by staff, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director verifies that community living center staff are aware of events warranting submission of a Joint Patient Safety Report and how to submit one.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2022
The VA Greater Los Angeles Health Care System Director evaluates the circumstances surrounding the death of the resident and determines if peer reviews of relevant clinical staff are warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The VA Greater Los Angeles Health Care System Director ensures that community living center managers receive training on the types of reviews, including quality assurance and administrative investigations and when each is appropriate for use, and documents attendance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director ensures that actions identified in the Corrective Action Plan are tracked to completion.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The VA Greater Los Angeles Health Care System Director confirms that an institutional disclosure is completed and documented to share that an “opportunity for intervention(transfer to the Emergency Department) existed and was considered but not acted on, prior to the terminal event.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director directs community living center leaders to review policy and admission processes to ensure respiratory therapy equipment needed in the care of a resident is in place at the time of admission.
Date Issued
|
Report Number
21-01361-192
|
Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/28/2023
Update the special-focused review standard operating procedure to require analysis of why errors occurred.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/3/2023
Establish controls to ensure special-focused review reports communicate both benefit entitlement and procedural errors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/3/2023
Establish controls to ensure special-focused review reports communicate all errors identified at both the national and regional office levels.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Implement a process to measure the effectiveness of actions taken in response to each special-focused review and determine whether a follow-up review is needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/28/2023
Reassess special-focused review errors marked as “corrected” to determine whether corrective actions were taken.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/5/2024

Assess whether an enhancement to the Quality Management System could mitigate the risk of claims processors closing special-focused review errors without correction and develop a process to ensure corrective actions are taken on all errors.

Date Issued
|
Report Number
21-02668-182
|
Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2024

Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024

Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2022
Clarify timeliness goals for the digital divide consult, and video device order placement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2023

Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024

Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2024

Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024

Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2024

Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
Augment tracking mechanisms for packages sent to patients to ensure VA receipt of the retrieval kit so that devices are accurately recorded in inventory and available for refurbishment and reissue.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024

Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,478,000.00
Date Issued
|
Report Number
21-02903-214
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2022
The Under Secretary for Health reviews vulnerabilities related to life-sustaining treatment processes and do not resuscitate orders within Veterans Health Administration facilities
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director evaluates staff’s reliance on the electronic health record as the definitive source for verification of life-sustaining treatment orders and patients’ code statuses and takes action as indicated
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director ensures that corrective actions from internal and quality management reviews are fully developed, implemented, and monitored for effectiveness.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director ensures that the electronic health record displays life-sustaining treatment orders where staff can easily locate the information.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director ensures that modifications to patients’ life-sustaining treatment orders, including do not resuscitate orders, are confirmed with the patient and surgical team and documented in the electronic health record prior to surgical procedures requiring anesthesia.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2022
The Michael E. DeBakey VA Medical Center Director determines that facility staff review patients’ code statuses for any changes upon patients’ return to units after surgical procedures.