Date Issued
|
Report Number
19-00223-166
All Reports
Date Issued
|
Report Number
18-04132-163
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/16/2020
The Bay Pines VA Healthcare System Director develops a policy to address patients with look-alike or soundalike names, educates staff on the use of the policy, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/16/2020
The Bay Pines VA Healthcare System Director implements missing patient documentation training for staff, and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/16/2020
The Bay Pines VA Healthcare System Director ensures that staff responsible for contacting outside facilities for missing patients receive training on their duties and responsibilities, and monitors compliance.
Date Issued
|
Report Number
17-05835-165
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/24/2020
The Veteran Integrated Service Network 10 Director ensures a case consult is made to Veterans Health Administration’s National Center for Ethics to consider whether the Chief of Staff used the position of authority in a manner intended to induce a patient management action which would have otherwise not been taken and, if so, whether the Chief of Staff’s conduct comports with a proper ethical standard.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/24/2020
The Northern Indiana Health Care Director verifies that the Pain Management Committee is providing oversight and monitoring of pain management activities as required by Veterans Health Administration policy and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Northern Indiana Health Care Director ensures monitoring of the quality of pain assessments and the effectiveness of pain management interventions and monitors compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director develops and implements a process to evaluate the success of meeting the goals of the Veterans Health Administration National Pain Management Strategy on a regular basis, at least yearly.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Northern Indiana Health Care Director establishes a formal transfer process for tertiary, interdisciplinary pain rehabilitation program referrals as required by Veterans Health Administration’s stepped care model for pain management.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director evaluates the educational programs offered to providers related to pain management and opioid safety to determine if the programs meet the intent of the Veterans Health Administration Pain Management Strategy for standardizing training and competencies and ensure that providers attend regularly.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/16/2019
The Northern Indiana Health Care Director ensures that the pain management team is operational as required by Veterans Health Administration.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/23/2020
The Northern Indiana Health Care Director ensures that the system policy is followed for providers to routinely review an opioid risk assessment for patients on long-term opioid therapy and monitors compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director verifies compliance with the system’s pain management policy regarding patients’ requests to change providers and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/24/2020
The Northern Indiana Health Care Director makes certain that primary care providers are utilizing the prescription drug monitoring program as required by Veterans Health Administration when prescribing opioid medication and monitors compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director ensures that primary care providers receive education on safe and effective Veterans Integrated Service Network tapering programs for patients using the combination of benzodiazepines and opioids and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Northern Indiana Health Care Director ensures that providers receive education on tapering programs for patients on high-risk opioids and monitors compliance.
Date Issued
|
Report Number
19-00497-161
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Veterans Integrated Service Network Director evaluates the quality and professionalism of Executive Leadership Team communications and takes action when indicated.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Veterans Integrated Service Network Director requires the development of, and follow-through on, corrective action plans responding to relevant findings from the National Center of Organizational Development’s 2018 site visits and reports.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director develops a process to ensure that Light Electronic Action Framework hiring requests are tracked and processed timely.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director reviews the facility’s hiring processes to identify opportunities to improve the efficiency and timeliness of hiring actions, and takes corrective action, as needed.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written critical care unit bed management policy that clearly states the process to be followed when an inpatient requires intensive care and a critical care unit bed is unavailable.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written policy regarding patient-owned medical devices and equipment that clearly outlines restrictions and acceptable uses when the patient is hospitalized.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a standardized method for documenting and ensuring compliance with the internal hand-off communication policy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures that neurosurgery privileges are amended to include only procedures which facility infrastructure can support.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director ensures that the nurse’s failure related to the computed tomography (CT) event outlined in this report is evaluated and administrative action is taken, as indicated.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director enhances processes to document Strategic Analytics for Improvement and Learning related improvement actions.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director continues efforts to improve patient and employee satisfaction.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures prompt evaluation of sentinel events, to include root cause analyses, in accordance with Veterans Health Administration requirements.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director evaluates the documentation failures related to Patient Y, and takes appropriate action, as indicated.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures the development of policy addressing the appropriate method for confirming and documenting nasogastric tube placement prior to administration of medications or tube feedings, including actions that should be taken when a nasogastric tube is partially dislodged.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to ensure that all registered nurses assigned to work in critical care units promptly complete assessments for missing unit-specific competencies.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to enhance processes to ensure that nursing competency skills assessments are specific to individual duty assignments and completed in accordance with Veterans Health Administration and facility policy.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Charlie Norwood VA Medical Center Director ensures that critical care unit staffing decisions include contingencies for staff absences.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical care unit and emergency department nurse vacancies, and ensure that until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures that unexcused nursing absences are managed in accordance with relevant Human Resource guidelines.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 9/16/2021
The Charlie Norwood VA Medical Center Director ensures that the emergency department security system is upgraded to meet current security requirements and to provide a safe environment for patients and staff.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical laboratory staff vacancies, and ensures that until optimal staffing is attained, alternate methods are consistently available that meet patient care needs.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures that before policy changes are made that impact the delivery of quality patient care, broad discussion with all key stakeholders takes place and written guidance is widely disseminated.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Charlie Norwood VA Medical Center Director ensures that policies and procedures regarding the appropriate transfer of critically ill patients are developed in conjunction with key stakeholders and that the process is widely disseminated to relevant staff.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 9/16/2021
The Charlie Norwood VA Medical Center Director ensures the Contracting Officer’s Representative responsible for the technical administration of the transportation contract conducts surveillance of the contractor’s performance and provides oversight of the contractual agreements.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 10/13/2020
The Charlie Norwood VA Medical Center Director ensures contingency plans are in place to rapidly mobilize staff when emergency department patients’ care demands exceed the current staffing resources.
No. 26
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Charlie Norwood VA Medical Center Director ensures there is a signed boarder policy, which is broadly disseminated.
No. 27
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Veterans Integrated Service Network Director completes an assessment of the facility’s ability to assure consistent availability of services and staffing to support providers’ professional practice and the safe and timely delivery of care, and takes action as necessary.
Date Issued
|
Report Number
18-06508-155
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substance storage areas on the day initiated and monitors the inspectors’ compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director ensures that controlled substances program staff reconcile the restocking/refilling from the pharmacy to every automated dispensing cabinet for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director ensures that controlled substances program staff reconcile the return of stock from every automated dispensing cabinet to the pharmacy for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The facility director confirms that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/20/2020
The chief of staff makes certain that clinicians provide and document patient/caregiver education specific to the newly prescribed medication and monitors clinicians’ compliance.
Date Issued
|
Report Number
17-05859-131
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 3/10/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction ensure there are adequate funds available to routinely conduct planning activities, including developing requests for lease proposals, for Strategic Capital Investment Planning approved major leases while waiting for congressional authorization.
No. 2
to Office of Management (OM)
Closure Date: 1/15/2020
The Assistant Secretary for Management and Chief Financial Officer reconsider centralizing major medical lease acquisition funding through VA’s acceptance of the completed building.
No. 3
to Office of Management (OM)
Closure Date: 3/10/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction obtain adequate resources to deliver leases on schedule.
No. 4
to Office of Management (OM)
Closure Date: 1/15/2020
The Assistant Secretary for Management ensure that the prospectus cost estimates provided to Congress are accurate and the costs are allocated appropriately to comply with OMB Circular A-11 requirements.
No. 5
to Office of Management (OM)
Closure Date: 1/15/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction implement a comprehensive VA policy for critical decisions in the lease acquisition process establishing clear lines of authority and allowable time frames.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 8/24/2021
The Deputy Under Secretary for Health for Operations and Management and the Executive Director, Office of Construction Facilities Management, ensure VA uses appropriate security measure requirements when acquiring VA major medical leases by performing Interagency Security Committee risk evaluations prior to solicitation.
No. 7
to Office of Management (OM)
Closure Date: 3/10/2020
The Executive Director, Office of Construction Facilities Management, ensure project acquisition teams are adequately trained in performance-based acquisition.
No. 8
to Office of Management (OM)
Closure Date: 3/10/2020
The Executive Director, Office of Construction Facilities Management, evaluate the use of consultants in the solicitation development process for Requests for Lease Proposals of major medical leases on a case-by-case basis.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 152,300,000.00
Date Issued
|
Report Number
18-03576-158
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The Veterans Integrated Service Network Director solicits an ethics consult regarding the patient’s final episode of care and treatment course including the failure to inform the patient or family of impending arrest and lack of family inclusion in decision-making.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director strengthens inpatient mental health unit processes to include the patient, family members, or surrogate in treatment and discharge planning decisions.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The Facility Director evaluates the inpatient mental health unit assessment practices of patients’ decision-making capacity and voluntary admission status, and takes actions as appropriate.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director ensures that facility staff identify and document patients’ surrogates accurately.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director ensures that inpatient mental health unit discharge processes include a complete medical and psychiatric diagnostic summary to patients’ receiving mental health providers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/20/2020
The Facility Director develops inpatient mental health unit discharge processes that include a clinical hand-off communication to patients’ receiving mental health providers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director ensures that a mental health treatment coordinator is assigned for patients during all episodes and levels of mental health care.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director ensures that informed consent is obtained from patients or authorized surrogates for release of information as required.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director evaluates inpatient mental health unit admission practices and develops processes in compliance with Veterans Health Administration policy regarding voluntary and involuntary admissions.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/26/2019
The Facility Director provides guidance to clinical staff regarding access to consultative resources such as forensic mental health experts, Office of General Counsel, and Ethics Consultation Service.
Date Issued
|
Report Number
18-00037-154
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health ensures facility medical staff bylaws are consistent with Veterans Health Administration policy regarding clinical pharmacist practice as non-independent practitioners.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Under Secretary for Health ensures collaborating agreements, also referenced as collaborative practice agreements, are in place for mental health clinical pharmacists who provide outpatient collaborative medication management.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health ensures that the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews existing Veterans Health Administration guidance and provides assistance in outlining the mental health clinical pharmacist’s responsibilities for communication with the collaborating licensed independent practitioner who has prescribing authority.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health affirms allowable clinical duties within mental health clinical pharmacists’ scopes of practice include comprehensive provisions related to mental health.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/7/2020
The Under Secretary for Health ensures a process is in place for chiefs of mental health service to document review, recommendation, and endorsement of all outpatient mental health clinical pharmacists’ scopes of practice, regardless of whether the clinical pharmacist is aligned with the mental health service line, and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews and provides input into the patient referral process to mental health clinical pharmacists with consideration for ensuring that accurate diagnoses can be reliably identified by and conveyed to the mental health clinical pharmacists.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews the patient referral process to mental health clinical pharmacists and provides input with consideration for clinical settings or scenarios in which a review of the clinical complexity of the referral by a licensed independent practitioner with prescribing authority would be appropriate, prior to treatment.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director establishes guidance and provides assistance in outlining when and how mental health clinical pharmacists are to refer patients to a higher level of mental health care.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The Under Secretary for Health initiates a risk assessment of outpatient mental health clinical pharmacists’ practice and establish mitigation plans; and includes the Veterans Health Administration Office of Mental Health and Suicide Prevention Director in the design, implementation, and analysis processes.
Date Issued
|
Report Number
19-00022-153
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Under Secretary for Health ensures that the planning and implementation of the new electronic medical record includes, (a) a fail-safe system that allows communication and tracking of test results to multiple clinical staff members who coordinate patient notification, appropriate follow-up testing and clinical management, and (b) the ability to monitor actions taken by the responsible provider(s).
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director initiates an administrative review of the clinical care the patient received and takes action as appropriate based on the results.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Veterans Integrated Service Network 15 Medical Facility Director ensures that Patient Centered Management Module provider and patient assignments are timely, and data are validated as required by Veterans Health Administration policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/18/2020
The Veterans Integrated Service Network 15 Medical Facility Director issues guidance that establishes a clearly-defined process for the designation of surrogates to include abnormal test results and consults.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Veterans Integrated Service Network 15 Medical Facility Director confirms that once issued, providers are trained on the process for designation of surrogates and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director reviews current view alert parameters, evaluates providers’ knowledge and management of view alerts, and takes action, as necessary, to ensure and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director evaluates communication among Patient Aligned Care Team members, including the sharing of, the timeliness of, and the response to patient secure messages, and takes action based on the evaluation.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews processes within Primary Care related to patient notification of test results and takes action to ensure test results are communicated to patients as required by Veterans Health Administration policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews Veterans Health Administration and the Veterans Integrated Service Network 15 Medical Facility policies concerning disclosure of adverse events to patients and/or their representatives and ensures that staff are aware of discussions and documentation required to comply with these policies.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews the events in the patient’s care and conducts additional actions related to the disclosure of adverse events to the patient’s representative as warranted by Veterans Health Administration and Veterans Integrated Service Network 15 Medical Facility.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews quality management practices and ensures compliance with Veterans Health Administration guidance related to root cause analysis when future adverse events are identified and takes action as necessary.
Date Issued
|
Report Number
19-00266-141
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/14/2019
Ensure VA vacancy data are reported by occupation as required by Section 505(a)(1)(c) of the Mission Act.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/14/2019
Make certain that VA staffing gains and losses data are reported by quarter as required by Section 505(a) part (b) of the MISSION Act.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/22/2020
Annotate limitations clearly within the staffing and vacancy data to improve transparency and usability of the data, to include changes from HR Smart data cleansing efforts.
No. 4
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/14/2019
Ensure that the staffing and vacancy reporting Web-site maintains historical information on the data elements required by the MISSION Act.
No. 5
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/22/2020
Update the methodology for collecting and reporting on VA staffing and vacancy data to ensure consistency in future quarters.
Date Issued
|
Report Number
18-02765-144
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/19/2019
The VA Eastern Kansas Health Care System Director implements documentation training for facility staff, including the Associate Chief of Staff for Education, and monitors compliance with out of operating room airway management documentation for completeness and accuracy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/19/2019
The VA Eastern Kansas Health Care System Director verifies that facility out of operating room airway management policy and out of operating room airway management providers comply with Veterans Health Administration requirements.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management staff are trained as required and monitor compliance, including tracking verification of out of operating room airway management competencies.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/19/2019
The VA Eastern Kansas Health Care System Director ensures that facility policy and use of Veterans Administration Form 10-0544, Privilege and Competency Verification, is consistent with VHA requirements.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management workgroups monitor progress toward implementation of Veterans Health Administration Directive 1157(1), Out of Operating Room Airway Management, June 14, 2018, Amended September 19, 2018.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
18-02765-144The VA Eastern Kansas Health Care System Director verifies that facility leaders review the VetPro process and ensures all credentialing and privileging files are complete as required by VHA policy and takes action as necessary based on the findings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The VA Eastern Kansas Health Care System Director verifies that the Cardiopulmonary Resuscitative Committee analyzes and aggregates data and implements desired changes, as outlined Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation, and monitors compliance.
Date Issued
|
Report Number
18-03260-102
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/6/2020
The Deputy Under Secretary for Health for Operations and Management directs the Healthcare Technology Management Program Office to clarify High Cost, High Tech approval requirements to Veterans Integrated Service Network 6 officials, including biomedical engineers, logistics staff, equipment specialists, and financial officers, and to the Veterans Health Administration Procurement and Logistics Office.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Veterans Integrated Service Network 6 network director updates and disseminates VHA requirements to request Assistant Deputy Under Secretary for Health for Administrative Operations approvals for High Cost, High Tech purchases that cost over $1 million, including surgical robots, to the members of the Veterans Integrated Service Network 6 Capital Investment Board and Veterans Integrated Service Network 6 staff.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Veterans Integrated Service Network 6 Capital Investment Board meets each fiscal year to ensure that all facility equipment requests more than $1 million are reviewed in a timely manner, including fiscal year-end purchases.
Date Issued
|
Report Number
18-04673-138
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff ensures utilization management reviewers complete at least 75 percent of all inpatient stay reviews and monitors the reviewers’ compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the Cardiopulmonary Resuscitation Committee’s compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated timeframes and monitors clinical managers’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director makes certain that controlled substances program staff perform one random day’s reconciliation of controlled substances returned to pharmacy from every automated dispensing unit during monthly inspections and monitors the program staff’s compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses and monitors controlled substances inspectors’ compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training requirements no later than 90 days after entering their position and monitors providers’ compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff ensures clinicians provide and document patient/caregiver education and monitors clinicians’ compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff makes certain that program managers implement a process for trackingcervical cancer screening data and monitors program managers’ compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The chief of staff confirms that providers notify patients of abnormal cervical pathology results within the required timeframe and monitors providers’ compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures that the urgent care center is discontinued and patient needs and flow are more adequately addressed in the established emergency department and primary care clinic, and monitors compliance.
Date Issued
|
Report Number
18-04676-142
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/22/2020
The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief Business Office revenue-utilization review and monitors the committee’s compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The facility director ensures the Acute and Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The chief of staff makes certain that the Medicine Service Line chief includes required gastroenterology-specific criteria in ongoing professional practice evaluations of gastroenterology practitioners and monitors the Medicine Service Line chief’s compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The associate director confirms storage rooms meet fire safety requirements by maintaining the required amount of open space between fire sprinkler deflectors and the top of stored items and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The associate director ensures that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The facility director makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/6/2020
The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/6/2020
The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/6/2020
The facility director confirms that the Women Veterans Health Committee includes required core members, designated members consistently attend meetings, and monitors the committee’s compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The chief of staff ensures that program managers implement a process for tracking results notification and follow-up care data for abnormal cervical cancer screenings and monitors program managers’ compliance.
Date Issued
|
Report Number
18-02405-146
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director ensures implementation of system-wide comprehensive environment of care practices and a safe, sanitary, and high-quality environment consistent with Veterans Health Administration policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The VA Loma Linda Health Care System Director makes certain that Environmental Management Service managers establish standard operating procedures and consistent processes for staff training.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The VA Loma Linda Health Care System Director implements a standardized process and accountability for validating Environmental Management Service staff competencies.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/22/2020
The VA Loma Linda Health Care System Director verifies compliance with Veterans Health Administration policies for Sterile Processing Services controls.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The VA Loma Linda Health Care System Director complies with Veterans Health Administration policies developed to support Infection Prevention and Control Program issues identified in this report.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director ensures that hot water temperature systems are 124 degrees Fahrenheit or higher to inhibit Legionella growth.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Healthcare System Chief of Staff and Associate Director of Patient Care Services implements a standardized process, consistent with Veterans Health Administration policy, to notify clinical staff involved in direct patient care when routine environmental water testing is positive for Legionella to increase diagnostic awareness.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The VA Loma Linda Health Care System Director continues to recruit and hire for hospitalist vacancies.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director monitors action plans for the Mental Health Strategic Analytics for Improvement and Learning measures.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/22/2020
The VA Loma Linda Health Care System Director completes a review of mental health staffing and continues efforts to recruit and hire for Mental Health Service vacancies.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The Veterans Integrated Service Network 22 Director verifies that the Loma Linda VA Health Care System Director implements action items from previous external Veterans Health Administration site reviews.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director makes certain that senior leaders consistently attend comprehensive environment of care monitoring rounds.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director designates staff members to consistently enter data into the Comprehensive Environment of Care Assessment and Compliance Tool and takes action, as necessary, to complete or address environment of care deficiencies to meet Environmental Program Service goals.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The Veterans Integrated Service Network 22 Director establishes a Veterans Integrated Service Network comprehensive environment of care policy and the VA Loma Linda Health Care System Director implements a facility level policy as required.
Date Issued
|
Report Number
17-04178-46
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/28/2021
The Technology Acquisition Center associate executive director provide written requirements, in designation memoranda or other written medium, that identify the method and level of detail required for program office contracting officers’ representatives to adequately document their review of contractor deliverables and determination of acceptability.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/28/2021
The Technology Acquisition Center associate executive director develop procedures for Technology Acquisition Center contracting officers to ensure review and acceptability of contractor deliverables is adequately documented in contract files to help prevent improper payments.
No. 3
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/14/2020
The Technology Acquisition Center associate executive director develop timeliness requirements for program office contracting officers’ representatives to submit contractor performance assessments.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/30/2020
The Technology Acquisition Center associate executive director develop written follow-up procedures that standardize the actions Technology Acquisition Center contracting officers should take when program office contracting officers’ representatives do not comply with the developed timeliness requirements.
No. 5
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/30/2020
The Technology Acquisition Center associate executive director implement procedures to monitor Technology Acquisition Center contracting officers’ actions through compliance reviews to ensure they adhere to written procedures.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/30/2020
The Technology Acquisition Center associate executive director assess the risk introduced by removing the requirement to review Past Performance Information Retrieval System records and implements a control that mitigates this risk.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/28/2021
The Technology Acquisition Center associate executive director enhance written procedures by providing Technology Acquisition Center contracting officers with standards that define higher-risk financial stability risk scores and subsequent actions that should be taken when these scores are identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,500,000.00
Date Issued
|
Report Number
17-03399-140
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The Gulf Coast Veterans Health Care System Director confirms current dermatology clinic nursing practice requirements related to ensuring informed consent prior to initiating phototherapy are followed and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The Gulf Coast Veterans Health Care System Director ensures dermatology clinic registered nurse training and competencies are completed as required and tracked for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Gulf Coast Veterans Health Care System Director reviews facility policy to ensure guidance clearly delineates environmental actions to be taken following identification of bed bugs.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The Gulf Coast Veterans Health Care System Director ensures that all Gulf Coast Veterans Health Care System staff are trained on the policy addressing environmental actions to be taken following identification of bed bugs and track compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Gulf Coast Veterans Health Care System Director ensures that the Patient Safety Manager completes all actions identified in the subject adverse event review.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/14/2019
The Veterans Integrated Service Network 16 Director reviews the Gulf Coast Veterans Health Care System policy related to the confidentiality of fact-finding reviews to evaluate if the initiation of such reviews, including the one conducted in relation to this patient, is consistent with the purpose of maintaining the confidentiality of quality management activities, and takes action as necessary.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Veterans Integrated Service Network 16 Director reviews and evaluates the proposed and actual disciplinary actions taken by Gulf Coast Veterans Health Care System managers related to the events of the day in question, and takes action as appropriate.
Date Issued
|
Report Number
18-04266-115
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/17/2021
The Under Secretary for Benefits improve the exam management systems to ensure visibility of the information needed to conduct adequate oversight of contracted disability exam cancellations.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2020
The Under Secretary for Benefits ensure staffing is sufficient so that the Medical Disability Examination Program can perform adequate oversight of contracted disability exam cancellations.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 6/10/2019
The Under Secretary for Benefits take steps to ensure that contracting officer’s representatives with oversight responsibilities for the Medical Disability Examination contracts achieve the VA-required certification level.
Date Issued
|
Report Number
18-03250-130
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2020
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees during the period from January 1, 2012, through December 31, 2017, and issue refunds.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2020
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees prior to January 1, 2012, and issue refunds.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 11/14/2019
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to mitigate the lack of real-time funding fee exemption status updates through system enhancements or procedural changes that minimize inappropriate funding fee charges.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2020
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to conduct periodic reviews to identify exempt veterans charged funding fees from January 1, 2018, forward, and issue refunds in a timely manner.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 11/14/2019
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to consistently obtain documentation and verify lenders apply funding fee refunds to veterans’ loan balances in a timely manner.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 352,600,000.00
Date Issued
|
Report Number
18-05864-127
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/30/2021
The Under Secretary for Health implement steps to achieve stated reduction targets for the following programs and activities: Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; and State Home Per Diem.