All Reports

Patient and Radiation Safety Concerns at the John D. Dingell VA Medical Center, Detroit, Michigan
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18-02210-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The John D. Dingell VA Medical Center Director ensures that radiologic equipment receives the required inspection and testing by a qualified medical physicist, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The John D. Dingell VA Medical Center Director ensures providers and radiology technicians complete fluoroscopy training as required, and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The John D. Dingell VA Medical Center Director ensures clinical privileges are granted in accordance with policy, and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The John D. Dingell VA Medical Center Director ensures that the radiology department conform to radiation safety standards as outlined through the National Health Physics Program and fully address any recommendations and violations, and monitors to completion.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The John D. Dingell VA Medical Center Director ensures that the Radiation Safety Committee minutes reflect actions taken to address National Health Physics Program recommendations and violations, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The John D. Dingell VA Medical Center Director ensures that the Radiation Safety Officer and Radiation Safety Committee initiate and utilize the Veterans Health Administration required tracking matrix to track unresolved action items to completion, and monitors compliance.
Accuracy of Claims Involving Service-Connected Amyotrophic Lateral Sclerosis
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18-00031-05

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/13/2020
The Under Secretary for Benefits implements a plan to improve the decisions and additional reviews of claims involving service-connected Amyotrophic Lateral Sclerosis, and monitors these claims to ensure staff demonstrate proficiency.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2020
The Under Secretary for Benefits implements a plan to ensure veterans with service-connected Amyotrophic Lateral Sclerosis receive notice regarding additional special monthly compensation benefits that may be available.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,800,000.00
Alleged Misuse of Government-Owned Vehicles at the Sacramento VA Medical Center, California
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17-04127-266

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2018
The VA Sierra Pacific Network Director confers with the Offices of General Counsel,Human Resources, and Accountability and Whistleblower Protection to determine theappropriate administrative action to take, if any, against Dr. Erckenbrack.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2018
The VA Sierra Pacific Network Director confers with the Offices of General Counsel,Human Resources, and Accountability and Whistleblower Protection to determine theappropriate administrative action to take, if any, against the Chief of LogisticsManagement Service.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2018
The VA Sierra Pacific Network Director confers with the Office of General Counsel andthe Director of the VA Northern California Health Care System to ensure that controlsare in place to oversee proper implementation by the Health Care System of federal law,regulations, and VA policy regarding the use of government-owned vehicles.
Alleged Concerns in Sterile Processing Services at the New Mexico VA Health Care System, Albuquerque, New Mexico
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17-04593-10

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2019
The New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the missing instrument procedures for sterile sets as required by Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2020
The New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the requirements for verification of items in sterile sets as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2019
The New Mexico VA Health Care System Director evaluates patient safety reporting systems to ensure that all events are captured in WebSPOT as required by Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2019
The New Mexico VA Health Care System Director ensures that all Sterile Processing Services staff, including contract staff, complete training as required by Veterans Health Administration Directive 1116 (2).
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The New Mexico VA Health Care System Director verifies that Sterile Processing Services managers maintain an accurate list for reusable medical equipment and copies of manufacturers’ instructions as required by Veterans Health Administration policy and the April 2017 Deputy Under Secretary for Health for Operations and Management memorandum.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The New Mexico VA Health Care System Director ensures that Sterile Processing Services maintain updated and readily accessible standard operating procedures for all instruments and equipment within Sterile Processing Services in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The New Mexico VA Health Care System Director ensures that competency assessments for all Sterile Processing Services staff, including contract staff, are conducted and documented as required by Veterans Health Administration Directive 1116 (2).
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2019
The New Mexico VA Health Care System Director reviews the contract related to Sterile Processing Services technicians to determine if requirements for training and certification are consistent with Veterans Health Administration Directive 1116 (2) and takes action as necessary.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Veterans Integrated Service Network 22 Director ensures that the New Mexico VA Health Care System Director implements action items from previous external Sterile Processing Services inspection reviews.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Veterans Integrated Service Network 22 Director oversees implementation of this report’s recommendations that are directed to the New Mexico VA Health Care System Director.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2020
The Veterans Integrated Service Network 22 Director reviews the New Mexico VA Health Care System’s Sterile Processing Services risk assessment to determine if identified high-risk items and areas are in alignment with guidance from the Deputy Under Secretary for Health for Operations and Management and takes action as necessary.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2020
The Veterans Integrated Service Network 22 implements a process that identifies instances when independent verification by Veterans Integrated Service Network staff is necessary to ensure that the Facility implements action plans related to Sterile Processing Services recommendations.
Emergency Cache Program: Ineffective Management Impairs Mission Readiness
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18-01496-301

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should develop requirements for medical facilities with emergency caches to perform at least annually a wall-to-wall inventory of all cache drugs and supplies, and develop processes to (1) label all expired or excess drugs that are purposefully maintained to respond to drug shortages or for the purposes of Shelf Life Extension testing, and (2) remove and rectify cases of other expired, missing, or excess drugs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should conduct an assessment to determine if the cost saving benefits of the Shelf Life Extension Program outweigh the risks expired drugs pose to the emergency cache’s mission and to take corrective action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Executive in Charge, Veterans Health Administration, should improve emergency cache inventory management processes to ensure emergency cache national inventory data sorted by location is reliable and accurately identifies the expiration dates of all cache contents, including Shelf Life Extension Program drugs, and that this information is electronically accessible to each facility.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program with a requirement for inventory to be timely rotated into the emergency cache after it is received.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should assess whether the Emergency Cache Program is properly aligned within VA and coordinate with other VA offices as necessary to determine the appropriate roles and responsibilities by program office, and then review, update, and reissue Emergency Cache Program requirements to include (1) robust annual cache inspection and activation exercise requirements, (2) processes to ensure cache inspection and activation requirements are met, (3) processes to ensure that violations identified during annual cache inspections are timely addressed, and (4) specific accountability measures for the program offices and local facility personnel responsible for program oversight.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Executive in Charge, Veterans Health Administration, should conduct a comprehensive assessment of the cache inventory to identify drugs and supplies that can be readily used in medical facilities’ general operations and develop a mechanism to monitor and ensure medical facilities are maximizing the use of these items before they expire.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2020
The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program to reflect the Office of Public Health’s reorganization and reassign responsibilities as needed.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 34,263,584.00
Comprehensive Healthcare Inspection Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia
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18-01136-313

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2019
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2019
The Facility Director ensures the interdisciplinary group or committee that reviews utilization management data includes required representatives and meets regularly and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2019
The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2019
The Chief of Staff ensures the Medical Executive Council uses and documents the use of the results of Ongoing Professional Practice Evaluations in the determination of whether to recommend continuation of licensed independent practitioners’ privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Associate Director ensures that damaged furniture is repaired or removed from service and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2019
The Associate Director ensures weekly inspections of the emergency power supply system are performed and documented and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2019
The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance dispensing from the pharmacy to automated dispensing cabinets and returns to pharmacy stock during monthly area inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2019
The Facility Director ensures that controlled substance inspectors verify controlled substance orders during monthly area inspections and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2019
The Associate Director for Patient Care Services ensures that all staff involved in inserting and managing central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Boston Healthcare System, Massachusetts
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17-05570-06

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2019
The Chief of Staff ensures that peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2019
The Chief of Staff ensures that Service Chiefs initiate and complete Focused Professional Practice Evaluations for newly hired licensed independent providers and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the review of service-specific practitioner data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The Chief of Staff ensures that Ongoing Professional Practice Evaluations of pathology practitioners include required pathology-specific criteria, as appropriate, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Deputy Director ensures that clean and dirty equipment is stored separately and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Deputy Director ensures that bottom shelves in equipment storage areas are solid and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/24/2018
The Facility Director ensures that deficiencies identified on the annual physical security survey are addressed and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Charles George VA Medical Center, Asheville, North Carolina
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18-01140-312

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2018
The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from the Chief Business Office Revenue–Utilization Review and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2019
The Facility Director ensures that the Patient Safety Manager or designee provides feedback to employees or departments who submit patient safety incidents that result in root cause analysis and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2019
The Director ensures that managers consistently implement improvement actions arising from peer review and root cause analysis activities and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Chief of Staff ensures that the Medical Staff Executive Council minutes consistently reflect the documents reviewed and the rationale to recommend approval of clinical privileges for license independent practitioners and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2019
The Chief of Staff ensures that clinical managers initiate and complete Focused and Ongoing Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2018
The Chief of Staff ensures that mammogram results are linked to radiology orders and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2018
The Chief of Staff ensures that mammogram results are communicated to ordering providers and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2018
The Chief of Staff ensures providers or designees communicate mammogram results to patients and monitors compliance.
Timeliness of Final Competency Determinations
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17-05535-292

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/22/2019
The Under Secretary for Benefits ensures cases requiring final competency determinations are entered into the Beneficiary Fiduciary Field System as soon as the cases are established in the Veterans Benefits Management System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits reminds Veterans Benefits Administration staff of their responsibility to notify Fiduciary Hubs when waivers are received of the due process notification period for cases with proposed incompetency, and implements a plan to ensure compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/22/2019
The Under Secretary for Benefits implements a plan to ensure the processing of final competency determinations under the jurisdiction of the Fiduciary Hubs meet Veterans Benefits Administration’s established timeliness standard.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2019
The Under Secretary for Benefits implements a plan to prioritize the processing of final competency determinations under the jurisdiction of Veterans Service Centers and Pension Management Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/7/2019
The Under Secretary for Benefits ensures the National Work Queue distributes final competency determinations according to the Veterans Benefits Administration policy for processing these cases.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits implements a plan to ensure Fiduciary Hub staff who complete final competency determinations have access to documents containing federal taxpayer information in the Legacy Content Manager.
VA’s Management of Land Use Under the West Los Angeles Leasing Act of 2016
|
18-00474-300

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Closure Date: 3/18/2026

The Principal Executive Director, Office of Acquisition, Logistics, and Construction and the Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System implement a plan that puts the West LA campus in compliance with the West Los Angeles Leasing Act of 2016, the Draft Master Plan, and other federal laws, including reasonable time periods to correct deficiencies noted in this report.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/25/2022
The Principal Executive Director, Office of Acquisition, Logistics, and Construction and the Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System ensure all non-VA entities operating on the West LA campus with expired or undocumented land use agreements establish new agreements compliant with the West Los Angeles Leasing Act.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2021
The Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System create a process to allow the Veterans Community Oversight and Engagement Board an opportunity to provide input to the executive leadership on West LA campus land use.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/17/2019
The Principal Executive Director, Office of Acquisition, Logistics, and Construction create documented policies and procedures for out leases and Revocable Licenses to govern their use, management, and pricing to ensure fair value is received and negotiations are documented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2020
The Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System ensure VA’s Capital Asset Inventory accurately reflects all land use agreements six months or longer on West LA campus.
Quality of Care Concerns Regarding a Patient Who had Cardiac Surgery at the VA Ann Arbor Healthcare System, Michigan
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17-04875-308

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Veterans Integrated System Network 10 Director ensures the VA Ann Arbor Healthcare System Director complies with Veterans Health Administration policies regarding requirements for root cause analysis, peer review, and institutional disclosure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The VA Ann Arbor Healthcare Facility Director applies quality management processes to evaluate modifications made by the anesthesiologist and surgeon for cardiothoracic surgeries and determines if modifications should be implemented system-wide.
Quality of Care Concerns in the Hemodialysis Unit at the Wilmington VA Medical Center, Delaware
|
17-03676-307

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director ensures that Hemodialysis Unit providers and staff are educated on laboratory and medication order urgency policy/processes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2019
The Wilmington VA Medical Center Director ensures that Facility leaders develop and implement a nursing policy that addresses verbal orders and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director ensures that Hemodialysis Unit providers receive training on the use of verbal orders including the use of verbal orders only in emergencies within the guidelines presented in the Facility bylaws and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director reviews Hemodialysis Unit staff access to and administration of medications to patients who do not have a medication order or the order has expired and takes actions as necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director ensures that a process is developed to notify Hemodialysis Unit staff of changes in hemodialysis orders and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Wilmington VA Medical Center Director ensures that the Hemodialysis Unit managers adopt and provide documentation programs that will enable accuracy and efficiency in record keeping and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2019
The Wilmington VA Medical Center Director ensures that the Code Blue members utilize the Code Blue Flow Sheet and that Rapid Response and Code Blue events are documented and presented monthly to the Facility’s Health Care Delivery Council.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Wilmington VA Medical Center Director ensures that the Education Department conducts unannounced mock code training twice a year in the Hemodialysis Unit with debriefings and monitors improvement and compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Wilmington VA Medical Center Director resolves the conflict between Hemodialysis Unit staff to provide a work place environment where staff collaborates to reduce the risk of adverse patient outcomes.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director evaluates the Facility’s education and training program to ensure that Safety Assessment Code assignments and Root Cause Analyses are conducted in accordance with Veterans Health Administration Handbook 1050.01, National Patient Safety Improvement.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director continues efforts to recruit and hire for Hemodialysis Unit staff vacancies, and ensures that, until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director ensures that the Chief of Medicine establishes a safe discharge process for hemodialysis patients including those who receive not routinely scheduled medications during hemodialysis and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director ensures Facility policies are consistent with Veterans Health Administration Handbook 1042.01, Criteria and Standards for VA Dialysis Programs, and Hemodialysis Unit providers and staff adhere to the policies.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2019
The Wilmington VA Medical Center Director ensures that the Facility Police Department act in alignment with VA Directive 0730 and Title 38 Code of Federal Regulations and takes actions as appropriate.
Comprehensive Healthcare Inspection Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
|
18-01143-302

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2019
The Chief Medical Executive ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
The Facility Director ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
The Chief Medical Executive ensures that the Credentialing and Privileging Subcommittee consistently review Focus Professional Practice Evaluations in the granting of continued privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2019
The Associate Director for Facility Support ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2019
The Facility Director ensures that deficiencies identified on the annual physical security survey are addressed and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Oklahoma City VA Health Care System, Oklahoma
|
18-01141-309

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2019
The Facility Director ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2019
The Facility Director ensures that the Quality, Safety, and Value Committee maintains oversight of all geriatric evaluation program quality improvement activities and monitors compliance.
Review of Mental Health Care Provided Prior to a Veteran’s Death by Suicide, Minneapolis VA Health Care System, Minnesota
|
18-02875-305

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Minneapolis VA Health Care System Director ensures that processes be strengthened to ensure MH interdisciplinary collaboration across levels of care in treatment planning, provision of clinical services and discharge planning, including medication management, as required by VHA.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Minneapolis VA Health Care System Director ensures that all MH interdisciplinary treatment team members, including the Suicide Prevention Coordinators and the outpatient care team, determine a patient’s “High Risk for Suicide” Patient Record Flag status prior to discharge.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Minneapolis VA Health Care System Director ensures that MH clinical documentation is accurate and includes documented attempts to obtain release of information and engage family in treatment, and documentation of lethality.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2019
The Minneapolis VA Health Care System Director verifies that all clinicians receive required training for Suicide Behavior Reporting.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2019
The Minneapolis VA Health Care System Director verifies that Suicide Prevention Coordinators complete Behavioral Health Autopsies within established VHA timeframes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Minneapolis VA Health Care System Director ensures that the Suicide Awareness Prevention Committee document action items, follow up plans and identifies responsible staff.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2019
The Minneapolis VA Health Care System Director ensures that processes be strengthened to ensure the root cause analysis process is performed consistent with VHA requirements.
Falsification of Blood Pressure Readings at the Berea Community Based Outpatient Clinic, Lexington, Kentucky
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18-01963-284

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: 9/20/2018
The Lexington VA Medical Center Director takes administrative action in relation to primary care provider 1, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2018
The Lexington VA Medical Center Director ensures patients impacted by blood pressure falsifications are evaluated and followed up.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2018
The Lexington VA Medical Center Director evaluates and takes appropriate action in relation to the four cases discussed in this report.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2019
The Lexington VA Medical Center Director develops processes to ensure the integrity of Veterans Health Administration Support Service Center data that supports performance metrics.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Lexington VA Medical Center Director ensures the development of policies and procedures governing primary care-based blood pressure readings and documentation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2019
The Lexington VA Medical Center Director evaluates the practices of primary care provider 1’s licensed practical nurse, and takes appropriate administrative action, if indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2018
The Lexington VA Medical Center Director requires retraining of Berea Community Based Outpatient Clinic staff on documentation requirements.
Alleged Inadequate Mental Health Treatment at the Dayton VA Medical Center, Ohio
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17-03382-294

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: 4/15/2019
The Dayton VA Medical Center Director ensures that the Mental Health Residential Rehabilitation Treatment Program nursing staff complete validated clinical scales to assess and quantify the severity of withdrawal symptoms for patients with opioid use disorder, as ordered.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The Dayton VA Medical Center Director ensures that the Mental Health Residential Rehabilitation Treatment Program provides timely therapeutic activity schedules to residents, including weekend treatment activities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2019
The Dayton VA Medical Center Director consults with the Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Office to evaluate whether the resident privileging levels program was congruent with the goals of the Mental Health Residential Rehabilitation Treatment Program, and take action as necessary.
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