All Reports

Healthcare Inspection – Mismanagement of Resuscitation and Other Concerns at the Buffalo VA Medical Center, Buffalo, New York
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17-01485-128

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 9/16/2019
We recommended that the VA Office of the General Counsel, pursuant to VA Directive 6311, work in conjunction with the Office of Information Technology, Veterans Health Administration offices, and other interested offices to advise the Under Secretary for Health regarding the refinement (or development) of policies reasonably designed to ensure the preservation of electronically stored information when legally necessary (or desirable for purposes of quality improvement), including, but not limited to electronically stored information that is subject to auto-deletion, such as telemetry data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Veterans Integrated Service Network Director conduct an evaluation of the Facility’s quality management practices (including but not limited to Root Cause Analyses, Issue Briefs, Administrative Investigation Boards, and Institutional Disclosures) to ensure that they align with Veterans Health Administration policies and also address the following specific deficiencies in this case: (a) the failure to conduct a Root Cause Analysis, (b) the failure to conduct a timely Administrative Investigation Board, (c) the failure to provide an Issue Brief, (d) the failure of the Administrative Investigation Board to consider all available evidence, and (e) the failure to make an Institutional Disclosure consistent with Veterans Health Administration Policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2018
We recommended that the Facility Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure that staff conduct interprofessional mock code training throughout the Facility with debriefing and monitor outcomes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director conduct an evaluation inclusive of, but not limited to, unit 9B and the Respiratory Department to determine if there are issues undermining teamwork at the work place, take action to address those issues, and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure that staff adhere to the Facility’s telemetry policy including, but not limited to, saving rhythm strips when a patient has a change in his/her baseline or a significant arrhythmia, that a competent staff member is always at the telemetry station, and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure that the Facility’s Education Department staff review the adequacy of its annual telemetry monitoring re-certification process including, but not limited to, evaluating whether to institute additional requirements for staff who rarely have practical experience in telemetry monitoring and establishing procedures to ensure that re-tests are conducted and tracked appropriately and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director evaluate the Respiratory Department handoff communications process including the timing of patients’ treatments and code status and modify as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the Facility Director ensure staff assess patients before and after breathing treatments, document the patient’s response in the electronic health record, and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2018
We recommended that the Facility Director review the content of Facility staff’s communication to the patient’s family and take corrective action if it is determined that the communication was insufficient to convey that the Facility was disclosing potentially inadequate care.
Healthcare Inspection – Alleged Patient Aligned Care Team Wait Time and Funding Issues at the Monterey Community Based Outpatient Clinic, VA Palo Alto Health Care System, Palo Alto, California
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17-02686-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that the System Director review human resources and clinic hiring processes for Patient Aligned Care Team staff and take action to minimize delays in filling vacancies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
We recommended that the System Director assess and ensure patient panel sizes for Patient Aligned Care Team providers are in compliance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2018
We recommended that the System Director ensure that Patient Aligned Care Team process improvement projects do not negatively affect clinic patient appointments.
Critical Deficiencies at the Washington DC VAMC
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17-02644-130

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The Medical Center Director ensures that necessary supplies, instruments, and equipment are available in patient care areas at the Medical Center when and where they are needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2019
The Medical Center Director requires operating room staff to conduct the final validation that all supplies, instruments, and equipment needed to perform the planned procedure and to address potential complications are in the operating room and available for use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2019
The Medical Center Director makes certain that the OR staff have accurate lists of surgical instruments needed for particular procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2019
The Under Secretary for Health specifies criteria under which individual medical centers will conduct wild card Aggregated Reviews for high-frequency patient safety events.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Medical Center Director ensures that routine audits of incident reporting system entries are completed to ascertain that all patient safety events are in the National Center for Patient Safety database as required by VHA policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Medical Center Director requires Medical Center oversight committees to follow up and initiate action as necessary on quality assurance matters related to supplies, instruments, or equipment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The Medical Center Director confirms the full utilization of a VHA authorized inventory system that contains accurate and reliable information regarding the availability of supplies throughout the Medical Center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Medical Center Director makes certain that the environmental integrity of clean/sterile storerooms complies with VHA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/8/2019
The Medical Center Director ensures there are clearly defined and effective procedures for replacing missing or broken instruments, and that staff responsible for this function have been educated on the process.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Medical Center Director confirms that clearly defined and effective procedures address the disposition of discolored instruments during reprocessing and that staff responsible for this function have been educated on the process.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
The Medical Center Director ensures that the Sterile Processing Service (SPS) implements a quality assurance program to verify the cleanliness, functionality, and completeness of instrument sets prior to their reaching clinical areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2019
The Medical Center Director makes certain that SPS and OR personnel comply with policies and procedures for the proper reprocessing of loaner instruments and trays.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director verifies that SPS managers maintain an accurate Master List for reusable medical equipment and file copies of manufacturer’s instructions as required by VHA policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Medical Center Director ensures that the SPS maintains updated and readily accessible standard operating procedures for all instruments and equipment within SPS and its satellite areas in accordance with VHA policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/30/2019
The Medical Center Director verifies that all SPS employees have appropriate, updated competencies and a demonstrated proficiency to perform their assigned duties.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The VISN 5 Director secures adequate space and funding for the Medical Center satellite reprocessing areas, which includes separate decontamination, processing, and packaging areas in accordance with VHA SPS policies.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2018
The VISN 5 Director makes certain that the Medical Center Director resolves open and pending prosthetic consults and implements a plan to address future prosthetic consults in accordance with VHA policy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director ensures the revision of Medical Center Fiscal Service practices to eliminate unnecessary cessations of prosthetic device purchasing, including at fiscal year-end.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The VISN 5 Director, together with Medical Center leaders, develops a staffing plan to fill vacancies that includes accurate numbers of authorized positions by service that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2019
The VISN 5 Director ensures the timely completion of hiring actions at the Medical Center until staffing deficiencies in Logistics Service and Sterile Processing Services are fully resolved.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2019
The Medical Center Director transitions purchase cards held by clinical staff and used for expendable medical supplies to Logistics Service staff, while ensuring that medical supplies can be obtained in a timely manner.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2019
The Medical Center Director ensures that medical supply items are added to the prime vendor formulary in order to meet prime vendor purchasing goals.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2019
The Medical Center Director makes certain that the Purchase Card Coordinator and approving officials monitor the issuance and future use of government purchase cards in accordance with VA Financial Policy.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2018
The Medical Center Director maintains segregation of duties between personnel who order and purchase expendable and nonexpendable items and those who receive the items.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The VISN 5 Director ensures that the Medical Center updates and maintains the Equipment Inventory List (EIL) as required by VA policy and makes certain that the Medical Center Director and Chief Logistics Officer are held accountable for the timely and accurate reporting of the Medical Center EIL.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director ensures that equipment is accurately and timely entered into the Automated Engineering Management System/Medical Equipment Reporting System.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2019
The Medical Center Director ensures that unrequired equipment is turned in for disposition consistent with VHA policies and procedures
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director properly secures all areas used to store medical equipment and supplies.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2019
The Medical Center Director designates an official records manager, alternate records manager, and official records liaisons, as well as implements a records management program in accordance with the National Archives and Records Administration requirements.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The Medical Center Director verifies that actions have been taken to notify patients when their information may have been improperly accessed, as appropriate.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The Medical Center Director verifies that accurate and complete financial documentation to support medical supply and equipment purchases is readily available in accordance with GAO Standards for Internal Control in the Federal Government.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2019
The VISN 5 Director audits a representative sample of FY 2017 Medical Center supply, instrument, and equipment purchases and ensures adequate internal controls for future purchases are in place.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The Deputy Under Secretary for Health for Operations and Management ensures that the VHA Procurement and Logistics Office conducts regular audits of the logistics services within VHA medical centers to assess compliance with VA and VHA policies pertaining to procurement and logistics, and makes certain that timely and effective remediation occurs in response to all noncompliant conditions identified as a result of those audits.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/10/2018
The VISN 5 Director evaluates the accuracy of representations made by Medical Center staff in connection with the completion of action plans arising out of the National Program Office of Sterile Processing October 2016 site visit and determines whether administrative actions should be taken as a result of those representations.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2019
The VISN 5 Director institutes procedures designed to ensure the accuracy of future representations made by Washington DC VA Medical Center staff in connection with action plans submitted to oversight bodies such as VHA program offices.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Under Secretary for Health clearly defines program offices’ responsibility for reporting high-priority recommendations to responsible individuals within VHACO, and requires independent verification that the relevant medical center and/or VISN have implemented the recommendations.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2018
The Under Secretary for Health develops a means of aggregating and analyzing available data on Logistics, Sterile Processing, Prosthetics, and Human Resources services (or other services as the Under Secretary for Health deems appropriate) so that major operational deficiencies at a medical center or VISN that affect multiple services or functions may be detected and corrected.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2019
The Under Secretary for Health takes appropriate administrative action to address the conditions identified in this report.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The VISN 5 Director oversees implementation of recommendations directed to the Medical Center Director.
No. 40
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The Under Secretary for Health verifies the successful implementation of all recommendations contained within this report.
Audit of Interior Design and Furnishing Contract Mismanagement by Network Contracting Office 21
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16-00409-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
The OIG recommended Service Area Office West Executive Director ensure the Network Contracting Office 21 Director implements the required integrated oversight process to perform the required pre-award contract reviews to ensure contracting officers’ compliance with Federal and VA acquisition regulations prior to contract award.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
The OIG recommended the Veterans Integrated Service Network 21 Director consult with the appropriate VA financial and legal officials to determine steps the Northern California Health Care System Director should take to remedy the violation of the bona fide needs rule.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2018
The OIG recommended the Service Area Office West Executive Directortake steps to ensure the Network Contracting Office 21 Director developand implement processes to effectively monitor the status of contractsand ensure contracting officers appropriately modify the contracts orclose them out in accordance with contract terms and the FederalAcquisition Regulation.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,300,000.00
Healthcare Inspection—Quality of Care and Patient Safety Concerns in the Community Living Center, James A. Haley VA Hospital, Tampa, Florida
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17-01491-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2018
We recommended that the Facility Director ensure that Community Living Center and Emergency Department staff understand and comply with policies for communication about residents requiring evaluation and treatment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that the Facility Director ensure that Community Living Center leaders develop a system to ensure fall precautions identified in the Falls Assessment are consistently reflected in the Individual Care Plan and implemented accordingly, and that staff are held accountable.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended that the Facility Director ensure the availability and functionality of fall prevention and safety devices such as hip protectors and chair alarms.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that the Facility Director ensure that Community Living Center leaders follow through on efforts to determine staff knowledge deficits related to fall prevention and institute training and process improvements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended that the Facility Director ensure that Community Living Center leaders conduct appropriate reviews and implement required actions in cases of suspected abuse or neglect.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended that the Facility Director ensure an adequate nurse staffing mix to meet the acuity levels and needs of the Community Living Center’s residents.
Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
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17-01746-116

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Facility Director ensures that a senior-level committee is established and responsible for key Quality, Safety, and Value functions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Facility Director ensures the Patient Safety Manager completes the required minimum of eight root cause analyses each fiscal year and monitors the manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Chief of Staff ensures that anticoagulation management program quality assurance data are analyzed and reported to the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians' compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Chief of Staff ensures clinicians consistently obtain and document all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians' compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Chief of Staff ensures all required elements specific to anticoagulation management are included in competency assessments for employees actively involved in the anticoagulant program and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Associate Director ensures environment of care inspections are conducted at the required frequency and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Chief of Staff and the Nurse Executive ensure that the Community Nursing Home Oversight Committee includes representation by all required disciplines and monitor compliance
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2018
The Nurse Executive ensures social workers conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitors social workers’ compliance.
Comprehensive Healthcare Inspection Program Review of the Hampton VA Medical Center, Hampton, Virginia
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17-01758-104

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2018
The Chief of Staff ensures that clinical managers communicate to the Peer Review Committee all completions of individual improvement actions and monitors managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data with the frequency required by facility policy and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff requires clinicians to ensure patients with newly prescribed warfarin have international normalized ratio measurements taken within 7 days of warfarin initiation, and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff requires clinical managers to complete competency assessments annually for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Chief of Staff ensures clinicians consistently include identification of the receiving provider in transfer documentation and monitors the clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures the Chesapeake community based outpatient clinic panic alarms are tested monthly and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures storage carts and shelves at the Chesapeake Community Based Outpatient Clinic have solid bottom shelves and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures locked mental health unit panic alarm testing includes documentation of VA Police response time and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training for identification and correction of environmental hazards and proper use of the Mental Health Environment of Care Checklist and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures providers include a history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures that physicians who perform or assist with moderate sedation procedures receive training for the provision of moderate sedation care prior to being re-privileged and that training is documented and monitors compliance with training and documentation.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Facility Director ensures that the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates processes into the facility’s quality improvement program with documentation of these processes in the facility’s executive-level committee meeting minutes and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and submits exclusionary criteria exemption requests when a community nursing home meets the threshold of four or more deficiencies and monitors the team’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors social workers’ and registered nurses’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures that Domiciliary Care for Homeless Veterans Program, general domiciliary, and Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees conduct and document daily resident room inspections for unsecured medications and monitors employees’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
Healthcare Inspection - Review of Montana Board of Psychologists Complaint and Assessment of VA Protocols for Traumatic Brain Injury Compensation and Pension Examinations
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15-01580-108

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Veterans Benefits Administration (VBA)
Closure Date: 7/6/2018
We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to ensure that personnel performing the traumatic brain injury Compensation and Pension examination have comprehensive training on the evaluation of traumatic brain injury, including the assessment and evaluation of cognitive disorders.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Veterans Benefits Administration (VBA)
Closure Date: 7/6/2018
We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to develop requirements for documentation of the traumatic brain injury Compensation and Pension examination process, including the basis for determinations of cognitive impairment and other residuals of traumatic brain injury.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Veterans Benefits Administration (VBA)
Closure Date: 5/9/2018
We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to consider whether to provide disability ratings to veterans with claims arising from cognitive issues based upon their clinical signs and symptoms, not primarily based upon the diagnosis or cause of their cognitive deficits (that is. traumatic brain injury or post-traumatic stress disorder).
Comprehensive Healthcare Inspection Program Review of the VA Northern California Health Care System, Mather, California
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17-01750-97

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2018
The Chief of Staff ensures service chiefs consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures pharmacy managers implement an anticoagulation management standard operating procedure that contains all elements required by the Veterans Health Administration.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2018
The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures clinicians consistently include patient or surrogate informed consent in transfer documentation and monitors clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
The Associate Directors ensure required team members participate on environment of care rounds and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Associate Director ensures VA Police conduct required testing of the locked mental health unit security surveillance television system and monitors VA Police compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures providers include the history of previous experience with sedation and anesthesia in the history and physical exams and/or pre-sedation assessments and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors the teams’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2018
The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required and monitors social workers’ and registered nurses’ compliance.
Administrative Investigation – VA Secretary and Delegation Travel to Europe
|
17-05909-106

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/14/2018
Secretary Shulkin reimburses the $4,312 paid by VA to cover Dr. Bari’s travel costs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/14/2018
Secretary Shulkin consults with the Office of General Counsel to determine the value of the Wimbledon tickets; grounds pass; and any food, parking, and other tangible benefits Ms. Gosling provided in connection with Wimbledon and reimburse that amount to her. If Ms. Gosling declines to accept reimbursement, Secretary Shulkin reimburses such amount to the US Treasury.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/14/2018
The Deputy Secretary of Veterans Affairs confers with the Offices of General Counsel, Human Resources, and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against Ms. Wright Simpson and any other individuals associated with the Europe trip.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/16/2018
The Deputy Secretary of Veterans Affairs ensures that a thorough audit is conducted of the expense vouchers, travel authorizations, and the time and attendance records for all travelers on the Europe trip. Any overpayments should be reimbursed to VA by the traveler and any required leave adjustments should be made. Detailed results of the audits, including supporting documentation, shall be provided to the Office of Inspector General no later than thirty days following the publication of this report.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/14/2018
The Deputy Secretary of Veterans Affairs ensures that the Office of General Counsel (i) reviews and enhances the training provided to staff on travel planning, approvals, and the solicitation or acceptance of gifts; and (ii) provides refresher training on these topics to all travelers on the Europe trip as well as all staff involved in the planning and implementation of the trip.
Comprehensive Healthcare Inspection Program Review of the Miami VA Healthcare System, Miami, Florida
|
17-01756-86

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The Facility Director ensures patient transfer data for transfers out of the facility are collected, analyzed, and reported to an identified quality oversight committee and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2019
The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record, and the Chief of Staff monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representation by all required disciplines, and demonstrates integration with the facility quality improvement program, and the Chief of Staff monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures the Community Nursing Home Review Team completes the required annual reviews for the community nursing homes and monitors managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2019
The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees in units 5A and 5D conduct and document daily resident room inspections for unsecured medications and monitors compliance.
Healthcare Inspection—Medical Foster Home Program Concerns, Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio
|
17-03860-100

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2018
The Under Secretary for Health amends Medical Foster Home policy to include processes for reporting Medical Foster Home revocations to appropriate authorities to ensure current and future resident safety.
Review of Excessive Procurement Costs at VHA’s Rural Outreach Clinic in Laughlin, Nevada
|
16-02695-51

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2018
The OIG recommended the Executive in Charge, Veterans Health Administration, ensure required oversight reviews are conducted and documented prior to the award of leases, contracting officers perform acquisitions in accordance with Department of Veterans Affairs and Federal Acquisition Regulation requirements, and awarded lease rates are in the best interest of the government.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2018
The OIG recommended the Executive in Charge, Veterans Health Administration, ensure the lease for the Laughlin Rural Outreach Clinicis is reevaluated to determine the financial advantages and disadvantages of renegotiating the terms of the contract to obtain a Fair Rental Value commensurate with the Laughlin Nevada area.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 290,010.00
Comprehensive Healthcare Inspection Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota
|
17-01745-96

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2019
The Facility Director ensures inter-facility patient transfer data are analyzed and reported to a quality oversight committee as part of the facility’s quality management program and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2018
The Associate Director ensures required team members participate in environment of care rounds and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2019
The Associate Director ensures the locked mental health unit’s seclusion room bed is secured to the floor.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2018
The Associate Director ensures that locked mental health unit employees and members of the Interdisciplinary Safety Inspection Team complete the required training for the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Associate Director monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Chief of Staff ensures that providers assess for patients’ previous adverse experiences with sedation or anesthesia prior to performing moderate sedation procedures and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2018
The Chief of Staff ensures that clinical team members conduct timeouts using a checklist with all the required elements prior to performing moderate sedation procedures and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA New York Harbor Healthcare System, New York, New York
|
17-01762-88

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2018
The Chief of Staff ensures Medicine Service clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2018
The Chief of Staff ensures quality assurance data for the anticoagulation management program are collected, analyzed, and reported quarterly at Pharmacy and Therapeutics Committee meetings and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2018
The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and refer patients prescribed direct-acting oral anticoagulants to the anticoagulation clinic and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2018
The Chief of Staff requires that clinical managers include in the competency assessments of employees actively involved in the anticoagulant program knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy, and the Chief of Staff monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2018
The Chief of Staff ensures inter-facility patient transfer data are analyzed and reported and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2018
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently complete VA Forms 10-2649A and 10-2649B as required by Veterans Integrated Service Network policy and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2018
The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information, and the Chief of Staff monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The Associate Director for Facilities and Human Resources ensures the VA Police Service consistently participates on environment of care rounds and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2018
The Associate Director for Facilities and Human Resources ensures locked mental health unit panic alarm testing documentation includes VA Police Service response time and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2018
The Associate Director for Patient Care Services ensures that a risk assessment is completed when a locked mental health unit patient is using an electrical or mechanical hospital bed and that the room containing the bed is locked when not in use, and the Associate Director for Patient Care Services monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2018
The Facility Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Facility Director monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2019
The Chief of Staff ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events for all areas administering moderate sedation are reported to and trended by the Surgical, Procedural, Operative, and Therapeutic Committee and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Chief of Staff ensures providers include a review of abnormalities of major organ systems; an airway assessment; and a review of alcohol, tobacco, or substance use or abuse in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2019
The Chief of Staff ensures providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and monitors providers’ compliance.
Comprehensive Healthcare Inspection Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas
|
17-01748-82

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Facility Director ensures revision of local policy to specify the Quality and Performance Council as the senior-level committee responsible for key quality, safety, and value functions and co-chairs this committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors physician advisors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Chief of Staff ensures that anticoagulation management program quality assurance data are collected, analyzed, and reported quarterly at the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Chief of Staff ensures clinical managers include anticoagulation-specific elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
The Facility Director ensures inter-facility patient transfer data are collected, reported, and analyzed as part of the facility’s quality management program and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Chief of Staff ensures transfer notes written by acceptable designees include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Associate Director ensures required team members consistently participate in environment of care rounds and monitors team members’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Associate Director ensures that VA Police perform and document system-wide panic alarm testing at the Salina community based outpatient clinic and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff ensures providers include an airway assessment in the history and physical examination and/or pre-sedation assessment and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff ensures clinicians perform post-procedure assessments of patient pain level and monitors clinicians’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Facility Director ensures the Community Nursing Home Oversight Committee continues to meet at least quarterly and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor social workers’ and registered nurses’ compliance.
Comprehensive Healthcare Inspection Program Review of the Central Alabama Veterans Health Care System, Montgomery, Alabama
|
17-01851-72

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently include patient or surrogate informed consent, medical and/or behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and monitors providers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2019
The Associate Director ensures the team members responsible for comprehensive EOC rounds consistently participate and use the Comprehensive Environment of Care Assessment and Compliance Tool to document results of those rounds and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The Associate Director ensures Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The Chief of Staff ensures that acceptable providers perform suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The Chief of Staff ensures that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of the referral and monitors providers’ compliance.
Comprehensive Healthcare Inspection Program Review of the West Texas VA Health Care System, Big Spring, Texas
|
17-01742-90

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Chief of Staff ensures clinicians consistently provide patient education specific for newly prescribed anticoagulant medications and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating warfarin and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility’s capacity and monitors providers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors providers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees document details of the observations and deficiencies identified during monthly self-inspections, submit work orders for all items needing repair, and document corrective actions taken, and the Chief of Staff monitors employees’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees consistently conduct and document weekly contraband inspections and monitors employees’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Associate Director ensures that Mental Health Residential Rehabilitation Treatment Program managers ensure that all doors not considered as the main point of entry have audible alarms and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2018
The Chief of Staff ensures that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2019
The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and refer them and monitors providers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures that acceptable providers complete diagnostic evaluations within 30 days for patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2018
The Chief of Staff ensures that resident physicians are assigned and granted the correct user class computer option and that clinical managers review and monitor residents’ progress notes to ensure that resident supervision documentation meets requirements, and the Chief of Staff monitors managers’ compliance.
Comprehensive Healthcare Inspection Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania
|
17-01855-81

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
The Associate Director ensures a safe respiratory environment for patients and employees in the Community Living Center units and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitor compliance.
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