All Reports

Comprehensive Healthcare Inspection of the Chalmers P. Wylie Ambulatory Care Center, Columbus, Ohio
|
19-00051-40

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: 10/8/2020
The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis to ensure quality and consistency of reviews and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director ensures that the appropriate committee reviews all resuscitative episodes, to include the required components, and monitors committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures that clinical managers define the focused professional practice evaluation process in advance and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff confirms that clinical managers ensure ongoing professional practice evaluations include service chief’s determination to continue privileges based on the results of the evaluations within the re-privileging period and monitors clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff makes certain that the facility’s Medical Executive Board considers ongoing professional practice evaluation results in its decision to recommend continuation of provider privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain that monthly and quarterly controlled substances inspection reports are reviewed at least on a quarterly basis by the facility committee responsible for quality oversight and that identified corrective actions are followed up until completion and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2021
The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2021
The chief of staff ensures that ordering providers notify patients of abnormal results within the required time frame and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The facility director ensures that the chief of staff makes certain that all anesthesia providers follow required steps to ensure consistent and safe handling, storage, and security of controlled substances and monitors compliance.
Comprehensive Healthcare Inspection of the Coatesville VA Medical Center, Pennsylvania
|
19-00048-48

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: 6/22/2020
The facility director makes certain that all required representatives consistently participate in the interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that managers consistently implement corrective actions identified in root cause analyses and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The chief of staff ensures that the Medical Executive Board reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2020
The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The associate director verifies that the inventory of resources and assets that may be needed during an emergency is documented and reviewed annually and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The associate director ensures that emergency generators are tested in accordance with required standards and results are documented and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that controlled substances inspectors are appointed in writing and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that the controlled substances coordinators complete annual competency assessment of inspectors and monitors coordinators’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The facility director makes certain that the controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities and monitors coordinators’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The chief of staff makes certain that clinicians document patient and/or caregiver understanding of the education provided about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The chief of staff makes certain the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that if the urgent care center operates 24 hours a day, seven days a week, that the national director of Emergency Medicine has approved a waiver.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors the center’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director ensures that support services are available to the urgent care center during all hours of operation and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain the urgent care center does not receive patients via ambulance and monitors compliance.
Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Order Fulfillment and Performance Reporting for Eastern Area Medical Centers
|
17-03718-240

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: 11/17/2025

The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to develop a formal process to validate correct order fulfillment reporting by the prime vendors, ensure the correct algorithms are used, and help prevent missed opportunities to identify and mitigate issues.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, requires the Healthcare Commodities Program Office to ensure Medical/Surgical Prime Vendor Next Generation contracting officer’s representatives get timely access to the performance metric reporting, such as reporting on correct order fulfillment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2021
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor contracting officer’s representatives to ensure performance metric reporting is reviewed for accuracy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2022
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to strengthen processes and procedures so that staff use the Medical/Surgical Prime Vendor Next Generation formulary to change unit of issuance and product pricing information in the item master files.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to confirm that prime vendor American Medical Depot uses formulary sources when fulfilling requests for medical or surgical products under the Medical/Surgical Prime Vendor Next Generation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, requires the director, VHA Procurement and Logistics Office, to see that all those who order supplies under the Medical/Surgical Prime Vendor-Next Generation contract have proper delegated authority.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2025

The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor the Integrated Product Team’s development and implementation of a process to validate performance metric reporting such as on unadjusted fill rates.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2025

The executive in charge, office of under secretary for health, requires the Procurement and Logistics Office to strengthen controls, monitor the Healthcare Commodities Program Office monthly, and ensure adherence to the established Medical/Surgical Prime Vendor Next Generation program control plan.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to identify and resolve discrepancies between unadjusted fill rate reporting methods used by the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, direct the Healthcare Commodities Program Office and Strategic Acquisition Center to see that all prime vendors use the unadjusted fill rate calculation methodology in accordance with the Medical/Surgical Prime Vendor Next Generation contract.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, instruct the Healthcare Commodities Program Office and Strategic Acquisition Center to require the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers to provide corrected unadjusted fill rates for the fiscal year 2018 and current reporting periods.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 84,000,000.00
Insufficient Oversight of VA’s Undelivered Orders
|
17-04859-196

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: 12/7/2020
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure relevant staff review and reconcile open orders to identify and deobligate excess funds for completed, canceled, or orders recorded more than once, and ensure the relevant staff follow existing policy regarding required reviews of open obligations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2020
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure that obligation policy includes specific time frames for effective interdepartmental communication to ensure timely identification of funds that are no longer needed for their original purpose and could be deobligated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM),Veterans Health Administration (VHA)
Closure Date: 11/27/2020
The assistant secretary for management and chief financial officer should develop a process for monitoring performance across the Department regarding reconciliation of open orders and develop a plan to share results with appropriate officials for their action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2020
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with existing policy, which requires that obligations be adjusted when actual costs of goods and services are known to be less than the initially recorded amount.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with policy, which requires that obligations be supported by sufficient documentary evidence that substantiates the validity and proper authorization of obligations and that the evidence be retained and readily available upon request.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2020
The Veterans Health Administration executive director for procurement should ensure timely modifications or closing of contracts, when applicable, to allow for the deobligation of funds no longer required.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 132,600,000.00
Comprehensive Healthcare Inspection of the Kansas City VA Medical Center, Missouri
|
18-06504-27

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: 8/5/2020
The chief of staff ensures that clinicians peer review all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff verifies that clinicians complete peer reviews of all completed suicides that occur within seven days after discharge from inpatient mental health treatment or residential care units and monitors clinicians’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The associate director ensures electronic safety data sheets are readily accessible to employees and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The associate director confirms that unit managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2020
The associate director ensures the mental health nursing station prevents unauthorized entry and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2019
The associate director ensures that the hazard vulnerability analysis and the emergency operations plan are approved by executive leadership and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The facility director ensures that controlled substances inspection program staff complete reconciliation of one random day’s return of stock to the pharmacy from every automated dispensing cabinet during monthly inspections and monitors program staff compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2020
The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The chief of staff ensures clinicians reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2020
The chief of staff makes certain that the Women Veterans Health Committee includes all required core members and monitors the committee’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2020
The chief of staff ensures the Women Veterans Health Committee reports to executive leaders and monitors the committee’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2019
The chief of staff makes certain that the emergency department director maintains a backup call schedule for emergency department providers and monitors the director’s compliance.
Comprehensive Healthcare Inspection of the VA Manila Outpatient Clinic, Pasay City, Philippines
|
19-00024-39

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: 8/27/2020
The chief medical officer ensures that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
The facility director makes certain that controlled substances inspectors perform a complete count of the pharmacy’s controlled substances physical inventory during monthly inspections and monitors inspectors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2020
The chief medical officer ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with facility leaders and monitors coordinator’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2020
The chief medical officer makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The chief medical officer ensures providers complete comprehensive diagnostic evaluations within the required time frame for all new patients referred for mental health services for military sexual trauma and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The chief medical officer makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The chief medical officer ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
Alleged Deficiencies in Oncology Psychosocial Distress Screening and Root Cause Analysis Processes at a Facility in VISN 15
|
19-06562-30

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: 9/11/2020
The Veterans Integrated Service Network Medical 15 Facility Director conducts an evaluation of radiation oncology clinic mental health consultation and treatment program needs and adjusts mental health provider coverage as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The Veterans Integrated Service Network Medical 15 Facility Director ensures that all components of the oncology service psychosocial distress screening standard operating procedures include screening frequency consistent with National Comprehensive Cancer Network’s ideal standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2020
The Veterans Integrated Service Network Medical 15 Facility Director guarantees that the patient safety program maintains effective processes to track action items to completion and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2020
The Veterans Integrated Service Network Medical 15 Facility Director ensures that staff complete Suicide Behavior and Overdose Reports and Behavioral Health Autopsies, as required by the Veterans Health Administration.
Comprehensive Healthcare Inspection of the VA Butler Health Care Center, Pennsylvania
|
19-00049-43

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: 12/17/2020
The chief of staff ensures that the Medical Executive Committee considers and documents the deliberation of professional practice data prior to granting privileges and monitors committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
Delays and Deficiencies in Management of Selected Radiology and Nuclear Medicine Outpatient Exams
|
18-02300-236

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: 12/2/2020
Ensure facility staff evaluate scheduling workload and that medical support assistant staffing is adequately distributed for scheduling radiology exam requests in a timely manner.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Provide formal guidance to facilities for establishing clinic management models for adequate radiology resources, including staffing and equipment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2021
Ensure facility radiology and nuclear medicine services monitor exam requests pending greater than seven days and address them in a timely manner.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
Confirm with each facility director that they reviewed each record and took appropriate action as they deemed necessary for the three completed requests with additional follow-up care needs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Develop and implement a plan for improved radiology and nuclear medicine oversight at the Veterans Integrated Service Network level.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2021
Implement a mechanism to routinely audit canceled exam requests, ensuring the requests are in accordance with VA radiology and nuclear medicine policies and procedures for canceling exam requests, and taking corrective actions as needed based on audit results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Create a method to notify radiology and nuclear medicine leaders at all VA medical facilities when guidance is released. The method should be streamlined with maximum distribution and ensure receipt and acknowledgment by affected radiology and nuclear medicine leaders.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
Confirm with each facility director that they review each record and take appropriate action for five of the six canceled requests with outstanding exam needs.
Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System, Honolulu, Hawaii
|
19-00023-29

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: 11/30/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff confirms that clinical managers ensure that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The associate director for Patient Care Services ensures staff remove expired medications from service and monitors staff compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The associate director for Patient Care Services makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The associate director makes certain staff use privacy screens on all computer monitors located in public areas and monitors staff compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The associate director ensures that the Leeward Oahu VA Clinic waiting room carpet is replaced.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff ensures that Leeward Oahu VA Clinic staff secure laboratory transport boxes containing personally identifiable information and monitors staff compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The facility director ensures that controlled substances inspectors verify controlledsubstances orders for five random dispensing activities during monthly area inspectionsand monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff confirms that mental health and primary care providers completemilitary sexual trauma mandatory training within the required time frame and monitorsproviders’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2020
The chief of staff confirms that the Women Veterans Health Committee is comprised of required members and monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The chief of staff makes certain that program managers collect and track cervical cancer screening notification, results reporting, and follow-up care data and monitors program managers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Comprehensive Healthcare Inspection of the Northern Arizona VA Health Care System, Prescott, Arizona
|
19-00014-33

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)
The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.
Comprehensive Healthcare Inspection of the Sioux Falls VA Health Care System, South Dakota
|
19-00019-26

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: 5/8/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2020
The chief of staff ensures that the imaging service chief includes the minimum required specialty-specific criteria for focused professional practice evaluations of nuclear medicine practitioners and monitors imaging service chief’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The associate director confirms that facility managers replace or remove damaged furnishings and wheelchairs from service and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substance orders and monitors inspectors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregivers education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The facility director ensures the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The facility director makes certain that the emergency department is staffed with a minimum of two registered nurses during all hours of operation and monitors compliance.
Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Boston VA Research Institute
|
18-00711-211

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 General Counsel (OGC),Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The under secretary for health confer with VA Office of General Counsel and the VA Boston Healthcare System Human Resources Office to determine if administrative actions should be taken concerning VA Boston Healthcare System officials responsible for the $1.6 million in inappropriate payments to the Boston VA Research Institute.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The under secretary for health determine appropriate actions for the inappropriate overpayments, made by VA Boston Healthcare System officials, associated with salaries and fringe benefits for ineligible Boston VA Research Institute administrative staff, as well as duplicate employer retirement contribution payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Human Resources Office develops procedures to require reviews of VA-affiliated nonprofit corporation Intergovernmental Personnel Act agreements for compliance with VA Handbook 5005, Staffing, prior to approval.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Research and Development Budget Office develops procedures for adequate review of VA-affiliated nonprofit corporation invoices to prevent duplicate payments in accordance with VA financial policy prior to approval.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The VA Boston Healthcare System director determine appropriate actions to ensure procedures are developed that require the VA Boston Healthcare System Research and Development Budget Office supervisor to conduct periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The VA Boston Healthcare System director establish procedures to ensure research and development budget office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with the agreement prior to payment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The VA Boston Healthcare System director establish procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff to prevent improper payments, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 45,903,000.00
Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System, California
|
18-04671-25

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: 4/6/2021
The chief of staff ensures that clinicians complete peer reviews for all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The associate director for Patient Care Services ensures utilization management reviewers complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors reviewers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The associate director for Patient Care Services ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The associate director for Patient Care Services makes certain that staff label multidose medication vials with an expiration date upon opening and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The associate director for Operations ensures that managers maintain a safe environment in patient care areas and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The associate director for Operations ensures that San Luis Obispo VA Clinic staff secure laboratory transport bags containing personally identifiable information and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2020
The associate director for Operations ensures the VA police document response times for panic alarm testing at the locked inpatient mental health unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The associate director for Operations makes certain that bathroom faucets in the inpatient mental health unit are in compliance with the Mental Health Environment of Care Checklist and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The facility director ensures that the controlled substances coordinator’s monthly summary report includes all discrepancies and findings identified during inspections and monitors coordinator’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2020
The facility director makes certain that a quality management committee consistently reviews monthly and quarterly controlled substances program trend reports, including discrepancies identified during inspections, and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The facility director makes certain that controlled substances inspectors are appointed in writing to a term not to exceed three years and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director ensures that the controlled substances coordinator performs and documents competency assessments of the controlled substances inspectors annually and monitors controlled substances coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director confirms that controlled substances inspectors complete monthly inspections and physical inventory counts and monitors inspectors’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors program staff’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2022
The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The facility director makes certain that the controlled substances coordinator refrains from conducting routine inspections and monitors coordinator’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2021
The facility director confirms that controlled substances inspectors complete monthly pharmacy inspections and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2022
The facility director ensures that controlled substances inspectors verify that drugs held for destruction are secured and documented during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2021
The facility director makes certain that controlled substances inspectors verify the inventory count of prescription pads the day of the pharmacy inspection and monitors inspectors’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2021
The facility director ensures that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The facility director guarantees that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2021
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2021
The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The chief of staff ensures that the Women Veterans Health Committee includes required core members, meets at least quarterly, and reports to facility leaders and monitors committee’s compliance.
Alleged Wrongful Death and Deficiencies in Documentation of a Patient’s DNAR Status at the Baltimore VA Medical Center, Maryland
|
19-05916-24

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: 7/29/2020
The VA Maryland Health Care System Director reviews the subject patient’s final episode of care and treatment course and determines if administrative actions are appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2021
The VA Maryland Health Care System Director establishes a process to monitor the identification, documentation, and communication of patients’ Do Not Attempt Resuscitation status.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Maryland Health Care System Director reviews the process for tracking, documenting, and completing action items in the Executive Committee of the Medical Staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The VA Maryland Health Care System Director strengthens the process for tracking code blue/rapid response events to include timely completion of the required documentation and accountability for delinquent documentation.
Comprehensive Healthcare Inspection of the El Paso VA Health Care System, Texas
|
19-00033-11

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: 12/16/2020
The chief of staff ensures that mental health service chiefs clearly define and communicate expectations for focused professional practice evaluations in advance with providers and monitors service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures the emergency management coordinator conducts an annual inventory of resources and assets and monitors coordinator’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The facility director ensures that an emergency operations plan that describes the response procedures to follow when emergencies occur is developed and maintained as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2020
The chief of staff makes certain that the Women Veterans Health Committee reports to leaders with signed minutes and monitors committee’s compliance.
Comprehensive Healthcare Inspection of the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
|
18-04667-13

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: 11/23/2020
The chief of staff ensures clinical managers initiate focused professional practice evaluations that clearly define criteria and communicate time frames in advance and monitors clinical managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The facility director ensures that pharmacy staff who review monthly balance adjustments do not have electronic access to perform controlled substances balance adjustments and monitors staff compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The facility director confirms that the Women Veterans Health Committee maintains an active charter, meets quarterly at a minimum, and reports to leadership with signed minutes and monitors committee’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2020
The chief of staff ensures providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.
Comprehensive Healthcare Inspection of the Manchester VA Medical Center, New Hampshire
|
19-00040-10

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: 10/19/2020
The facility director confirms that the patient safety manager includes consideration of relevant literature in root cause analyses and monitors patient safety manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The chief of staff ensures that clinical managers document in practitioners’ profiles the focused professional practice evaluation criteria defined in advance and monitors clinical managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The chief of staff ensures that professional practice evaluations include service-specific criteria and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The chief of staff confirms that specialty providers’ ongoing professional practice evaluations include the minimum required specialty criteria and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The chief of staff makes certain that the facility’s Medical Executive Council reviews the professional practice data in the consideration to continue provider privileges and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The associate director ensures that a clean and safe environment is maintained throughout the facility and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The facility director ensures that military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The chief of staff ensures providers offer referrals for military sexual trauma-related services for patients with a positive screen and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The chief of staff ensures providers document indication for use for newly prescribed medications in patients’ electronic health records and monitors providers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The chief of staff ensures providers reconcile medication information and resolve discrepancies and monitors the providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2020
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center, Augusta, Georgia
|
19-00013-15

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: 4/14/2020
The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors manager compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The chief of staff ensures that final peer reviews are completed within 120 calendar days from the determination of the need for the review, or there is an extension approved in writing by the director, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The facility director makes certain that a summary of the Peer Review Committee’s work is reviewed quarterly by the executive level medical committee and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2021
The chief of staff makes certain that service chiefs define and communicate expectations for focused professional practice evaluation criteria in advance and maintain appropriate documentation of the processes and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2020
The associate director ensures a clean and safe environment is maintained throughout the facility and monitors team’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The associate director ensures the facility maintains an inventory of assets and resources available in the event of a disaster and that it is reviewed annually and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The associate director validates that the facility’s emergency operations plan includes all required elements and is reviewed annually and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that the controlled substances coordinator submits monthly summary of findings and quarterly trends, that include discrepancies and vulnerabilities, to the director and monitors controlled substances coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The facility director makes certain that the appropriate quality management committee reviews the controlled substances monthly and quarterly reports at least on a quarterly basis and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain the controlled substances coordinator conducts required annual competency assessments of the controlled substances inspectors and monitors the coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substances in storage areas on the day initiated and monitors inspectors’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that reconciliation of one day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during monthly controlled substances area inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substances orders during monthly area inspections and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that controlled substances inspectors verify, during monthly inspections, there is a corresponding sealed evidence bag containing drug(s) for each destruction holding number listed on the “Destructions File Holding Report” and monitors inspector’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director ensures that controlled substances inspectors complete verification of prescription pad inventories count during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director ensures that the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances prescriptions during monthly area inspections and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director makes certain that controlled substances inspectors complete the verification of the 72-hour inventory and monitors inspectors’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The chief of staff ensures providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The facility director confirms that the committee responsible for Women Veterans Subcommittee meets quarterly and includes required core members and monitors committee’s compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The facility director ensures that assigned staff implement a process to track and follow-up on findings from cervical cancer screenings and monitors staff’s compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The chief of staff ensures that a backup call schedule is maintained for emergency department providers and monitors the department’s compliance.
VHA Did Not Effectively Manage Appeals of Non VA Care Claims
|
18-06294-213

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: 12/2/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate identifies its facilities that receive appeals but do not have sufficient staff assigned to process them, and then promptly transfers unprocessed appeals from those facilities to a Payment Operations and Management appeals-processing facility to ensure they are processed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate updates communications to direct claimants to submit appeals to its facilities with designated appeals-processing staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health clearly define the roles and responsibilities of an accountable OCC official to oversee the Payment Operations and Management directorate’s appeals function.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates effective policies and procedures for its staff to promptly process their pending appeals workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate completely and accurately identifies and records its pending appeals inventory in a standard system of record and implements controls to effectively maintain the pending appeals inventory in the system of record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure all Payment Operations and Management directorate appeals processors obtain access to Caseflow promptly, and that Caseflow includes fields that are necessary to effectively manage Payment Operations and Management appeals.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates to all staff effective policies and procedures for processing and managing appeals under the new appeals process, including timeliness standards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Under Secretary for Health ensure the Payment Operations and Management directorate completes a comprehensive assessment of its appeals workforce and inventory, and then reevaluates its appeals staffing needs.
Displaying 981 - 1000 of 4254