All Reports
Date Issued
|
Report Number
17-02079-328
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/19/2018
We recommended that the San Juan VA Regional Office Director develop and implement a plan to ensure secondary reviewers accurately evaluate higher-level special monthly compensation and ancillary benefits claims.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/14/2018
We recommended that the San Juan VA Regional Office Director implement a plan to ensure Veterans Service Center claims processing staff receive additional training on systems compliance and claims establishment procedures.
Date Issued
|
Report Number
16-00552-341
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/19/2018
We recommended that facility managers ensure floors and rolling equipment in patient care areas are clean and in good repair and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that the facility review quality assurance data for the anticoagulation management program monthly at Pharmacy and Therapeutics Committee meetings and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulants.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments 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 that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
We recommended that the laboratory director develop and implement a process to ensure employee competency for point-of-care testing with glucometers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that the laboratory director ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Date Issued
|
Report Number
17-02150-340
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 3/20/2018
We recommended the St. Louis VA Regional Office Director implement a plan to provide refresher training on Special Monthly Compensation and monitor the effectiveness of that training.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 3/20/2018
We recommended the St. Louis VA Regional Office Director implement a plan to ensure Special Monthly Compensation rating decisions receive a second signature review by a designated subject matter expert for processing.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 3/20/2018
We recommended the St. Louis VA Regional Office Director implement a training plan, conducted by qualified staff, on the proper processing of rating reductions, and monitor the effectiveness of that training.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/7/2017
We recommended the St. Louis VA Regional Office Director implement a plan to ensure rating reduction cases are processed at the end of the due process time period to minimize overpayments.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 3/20/2018
We recommended the St. Louis VA Regional Office Director implement a plan to monitor the effectiveness of recent training for claims establishment.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/5/2018
We recommended the St. Louis VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 2/5/2018
We recommended the St. Louis VA Regional Office Director implement a training plan on how to properly process special controlled correspondence, and monitor the effectiveness of that training.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 9/7/2017
We recommended the St. Louis VA Regional Office Director allocate resources to process special controlled correspondence to ensure timely responses.
Date Issued
|
Report Number
17-00712-366
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/22/2018
We recommended that the Veterans Integrated Service Network 12 Director improve oversight of the Dental Clinic by performing unannounced inspections that include opportunities to interview staff privately regarding any concerns.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/22/2018
We recommended that the Facility Director improve oversight of the Dental Clinic by conducting unannounced, detailed inspections to ensure adherence to Veterans Health Administration and facility infection control standards, patient safety guidelines, and other pertinent dental policies and procedures.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/22/2018
We recommended that the Facility Director conduct training on when it is appropriate to report issues relating to the quality of healthcare or patient safety issues and the various options on where to report.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/10/2017
We recommended that the Facility Director consult with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action, if any, for staff who failed to report the reuse of unsterile burs on patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/22/2018
We recommended that the Facility Director ensure Environment of Care rounds are scheduled when all areas of the Dental Clinic are available to be inspected.
Date Issued
|
Report Number
14-03822-359
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the Amarillo VA Health Care System Director ensure that community based outpatient clinics are appropriately staffed to provide care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the Amarillo VA Health Care System Director ensure that managers conduct clinical reviews of the three Clovis Community Based Outpatient Clinic patients discussed in this report to determine whether a delay in follow-up adversely affected their outcomes and take action as appropriate.
Date Issued
|
Report Number
15-03288-362
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/24/2018
We recommended that the Facility Director ensure that Urgent Care Clinic providers consistently transfer stroke patients to an appropriate acute care facility in accordance with Veterans Health Administration and facility policies and procedures.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/7/2017
We recommended that the Facility Director ensure that the Peer Review Committee follows Veterans Health Administration policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/7/2017
We recommended that the Facility Director ensure that facility managers clinically review the records of the 13 patients not transferred to the non-VA acute care hospital, approximately 2.5 miles away, to determine whether patient harm occurred and take action as appropriate.
Date Issued
|
Report Number
15-05020-278
Date Issued
|
Report Number
17-00970-327
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2018
We recommended the Wilmington VA Regional Office Director implement a plan to assess the effectiveness of second-signature reviews for Special Monthly Compensation and Ancillary Benefits claims.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2018
We recommended the Wilmington VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for higher-level Special Monthly Compensation and Ancillary Benefits.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2018
We recommended that the Wilmington VA Regional Office Director implement a plan to ensure management provides a consistent quality review process which addresses all elements required when establishing claims in the electronic record and monitor the effectiveness of that plan.
Date Issued
|
Report Number
16-02526-358
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/22/2018
We recommended that the Facility Director ensure that consult clinical reviews and appointment scheduling for patients are conducted in compliance with Veterans Health Administration directives and system policies.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that Physical Medicine and Rehabilitation Services have sufficient staffing to arrange for timely consultations and appointments within the service.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/10/2018
We recommended that the Facility staff who schedule Physical Medicine and Rehabilitation Services patient appointments receive annual scheduling competencies to ensure understanding of the correct process for compliance with Veterans Health Administration directives and staff are monitored for compliance.
Date Issued
|
Report Number
17-01354-336
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2018
We recommended the Denver VA Regional Director implement a plan to complete proposed rating reduction cases at the end of the due process period.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/23/2018
We recommended that the Denver VA Regional Office Director implement a plan to ensure all claims processing staff receive formal training on claims establishment procedures and monitor the effectiveness of that training.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2018
We recommended the Denver VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2018
We recommended the Denver VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
Date Issued
|
Report Number
15-00650-353
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/29/2017
We recommended that the Facility Director ensure that outpatient echocardiography and stress test consult requests are scheduled and completed in accordance with Veterans Health Administration policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/29/2017
We recommended that the Facility Director ensure that sleep study consult requests are scheduled and completed within the timeframe required by Veterans Health Administration policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that the Facility Director ensure that patients’ cardiac diagnostic and procedure reports are signed within the timeframe specified by policy to ensure appropriate follow-up and patient care coordination.
Date Issued
|
Report Number
17-01276-300
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/24/2017
We recommended the Philadelphia VA Regional Office Director develop and implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/24/2017
We recommended the Philadelphia VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Philadelphia VA Regional Office Director implement a plan to assess the effectiveness of the most recent claims establishment training.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Philadelphia VA Regional Office Director provide training on special controlled correspondence to ensure accurate and complete responses to the veteran and Congressional staff, and monitor the effectiveness of the training.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Philadelphia VA Regional Office Director improve oversight of special controlled correspondence.
Date Issued
|
Report Number
15-03418-350
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers strengthen patient flow processes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/26/2018
We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers evaluate staff's Emergency Department Integrated Software data entry and implement action plans to ensure data accuracy and timeliness.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the Veterans Integrated Service Network Director ensure that the VA Maryland Health Care System managers strengthen Patient Flow Committee processes to include the establishment of patient flow goals, action target dates, and oversight of action implementation.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that the System Director ensure that policy regarding patients boarding in the Emergency Department include all required elements.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the System Director strengthen Bed Management Solution utilization and processes, and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
We recommended that the System Director strengthen processes to improve timeliness of bed cleaning.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/14/2018
We recommended that the System Director review the impact of inpatient medicine admission capping and establish alternative plans that improve patient flow from the Emergency Department, monitor outcomes, and implement alternative plans as warranted.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
We recommended that the System Director review and address processes that contribute to delays of inpatient discharge.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
We recommended that the System Director strengthen nursing service communication processes to ensure consistent inpatient care coverage and nurses' availability for Emergency Department handoff.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that the System Director evaluate the adequacy of Emergency Department administrative support staffing and take appropriate action.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
We recommended that the System Director improve and monitor compliance with response time requirements for after-hour computerized tomography scan services.
Date Issued
|
Report Number
17-00394-298
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2018
We recommended the Louisville VA Regional Office Director assess the effectiveness of the most recent refresher training for higher level special monthly compensation.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2018
We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight and assess the accuracy of secondary reviews involving higher-level special monthly compensation and ancillary benefits.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/23/2017
We recommended the Louisville VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 8/23/2017
We recommended the Louisville VA Regional Office Director implement a plan to conduct training that emphasizes date of claim policies and accurate contention classifications, and to monitor the effectiveness of the training.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 8/23/2017
We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight for newly hired staff who establish claims.
Date Issued
|
Report Number
15-02156-346
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/23/2018
We recommended that the Veterans Integrated Service Network Director convene an expert panel knowledgeable in the subspecialties of Pain Medicine and Addiction Medicine to review the subject provider’s opioid prescribing practices within the context of the patients whose treatment varied from guidelines as described in this report, ensure that the expert panel expand the review as necessary, and submit a report of findings to the Veterans Integrated Service Network and Facility Directors.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that the Veterans Integrated Service Network Director ensure the monitoring patients on Suboxone.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/22/2017
We recommended that the Veterans Integrated Service Network Director ensure the Pain Committee strengthens processes to improve communication with the facility to ensure information is relayed timely.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/23/2018
We recommended that the Facility Director ensure that providers access the Prescription Drug Monitoring Program database as required by facility policy and monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that the Facility Director ensure adequate resources, such as additional staff or allotted duty time, are allocated for patient reviews for opioid therapy appropriateness.
Date Issued
|
Report Number
16-02160-344
Date Issued
|
Report Number
17-00515-299
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/20/2018
We recommended the Phoenix VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for special monthly compensation rating decisions and perform an effective review.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Phoenix VA Regional Office Director implement a plan to improve the second signature review process for special monthly compensation rating decisions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/17/2017
We recommended the Phoenix VA Regional Director implement a plan to prioritize proposed rating reduction cases for completion at the end of the due process time period.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Phoenix VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is accurate.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 4/20/2018
We recommended the Phoenix VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Phoenix VA Regional Office Director provide training to congressional liaisons on special controlled correspondence to ensure all documents are included in the electronic record in accordance with current Veterans Benefits Administration guidance.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Phoenix VA Regional Office Director update the office’s local procedures relating to special controlled correspondence in accordance with current Veterans Benefits Administration procedures.
Date Issued
|
Report Number
16-02998-345
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/19/2018
We recommended that the VA New York Harbor Healthcare System Director consult with the Office of Chief Counsel regarding possible institutional disclosure to Patient A’s family.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/19/2018
We recommended that the VA New York Harbor Healthcare System Director ensure that processes are developed to track whether and when orders for pressure-reducing mattresses or overlays are satisfied.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/19/2018
We recommended that the VA New York Harbor Healthcare System Director ensure that staff have the capability to order and receive pressure-reducing mattresses and overlays for patients during “off tour” hours, including nights, weekends, and holidays.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/2/2019
We recommended that the VA New York Harbor Healthcare System Director ensure that pressure ulcer-related documentation adheres to VHA policy.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/19/2018
We recommended that the VA New York Harbor Healthcare System Director consider the appropriateness of updating the nursing discharge documentation to prompt staff to complete skin assessments proximal to the time of discharge.
Date Issued
|
Report Number
16-00597-279
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/17/2017
We recommended the South Texas Veterans Health Care System Director require staff to review all pending orders that are past due to identify those orders which are active and those which need to be canceled because they have been completed or are no longer needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/17/2017
We recommended the South Texas Veterans Health Care System Director develop a plan to address any pending exams that are past due to ensure patients who have experienced significant delays receive needed exams.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/17/2017
We recommended the South Texas Veterans Health Care System Director ensure staff review the health care system’s current hard copy scheduling process to reduce inefficiencies related to duplicate orders, inaccurate record keeping, and the inventory of pending orders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/17/2017
We recommended the South Texas Veterans Health Care System Director ensure Imaging Service staff implement VHA’s Outpatient Radiology Scheduling Policy and Procedures and establish monitoring mechanisms where staff review pending orders at designated intervals and remove duplicate exams to facilitate the timely completion of exams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/17/2017
We recommended the South Texas Veterans Health Care System Director implement a program to educate and remind clinicians of the processes they should use to avoid the creation of unnecessary duplicate orders.