All Reports

Inspection of the VA Regional Office Phoenix, Arizona
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17-00515-299

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Pressure Ulcer Prevention and Management, VA New York Harbor Healthcare System, New York, New York
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16-02998-345

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Audit of VHA's Imaging Service Scheduling Practices in the South Texas Veterans Health Care System
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16-00597-279

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Healthcare Inspection – Quality of Care Concerns in Thoracic Surgery, Bay Pines VA Healthcare System, Bay Pines, Florida
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17-00602-342

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that the System Director ensure that focused professional practice evaluations review criteria are sufficient to evaluate the privilege-specific competence for thoracic surgeons.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2017
We recommended that the System Director ensure that ongoing professional practice evaluation reviews are conducted by providers with training and privileges similar to those of the provider under review.
Clinical Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana
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16-00577-335

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that facility managers ensure clean bed frames in patient care areas and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2017
We recommended that the facility designate a physician anticoagulation program champion.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2018
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that facility managers 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 that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that the facility’s Disruptive Behavior Committee include a senior clinician chair and the Patient Safety Manager and/or Risk Manager and that the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
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.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that that the Medical Executive Committee discuss and document its approval of the use of another facility’s physicians for teledermatology services.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.
Clinical Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania
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16-00555-337

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the facility consistently take action when data analyses indicated problems or opportunities for improvement and evaluate the actions for effectiveness in peer review and Focused Professional Practice Evaluations and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2018
We recommended that the facility Chief of Staff ensure that all required practitioners are designated as members of the medical staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2017
We recommended that facility managers ensure the access log for the Huntingdon County VA Clinic information technology network room includes all required elements to document access and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2017
We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Huntingdon County VA Clinic and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the facility designate a physician anticoagulation program champion.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommended that facility managers ensure integration of the community nursing home program into its quality improvement program.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2018
We recommended that facility managers 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 that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2018
We recommended that a VA physician order or approve all therapies that are at VA expense.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
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 training is documented in employee training records.
Audit of the VHA's Health Care Enrollment Program at Medical Facilities
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16-00355-296

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
We recommended the Acting Under Secretary for Health develop standardized national policy and procedures for the health care enrollment program at VA medical facilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
We recommended the Acting Under Secretary for Health implement national oversight of the health care enrollment program to continually review operations and performance of VHA medical facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2019
We recommended the Acting Under Secretary for Health provide mandatory and standardized training on eligibility and enrollment to ensure health care applications are processed accurately and timely.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2020
We recommended the Acting Under Secretary for Health develop and execute a process to distinguish new applications for health care enrollment in VistA from other registration data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2020
We recommended the Acting Under Secretary for Health implement a plan to correct current data integrity issues in VistA to improve the accuracy and timeliness of enrollment data.
Inspection of the VA Regional Office Atlanta, Georgia
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16-05468-282

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases are appropriately distributed to the most qualifiedpersonnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to monitor the effectiveness of training on higher-level SpecialMonthly Compensation and Ancillary Benefits.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases receive an accurate, signed second-level review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Southeast District Director implement a plan toensure the Atlanta VA Regional Office Director provides oversight andprioritization of proposed rating reductions claims for completion at theend of the due process period.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended that the Atlanta VA Regional Office Director ensureclaims assistants receive all systems compliance related training relevantto claims establishment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended that the Atlanta VA Regional Office Directorimplement a plan to modify the quality review checklist on claimsestablishment to include claim label and claimed issue classification indicators for all claims.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure claims processing staff properly establish and maintainend product 500s for control of special controlled correspondence.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2018
We recommended the Atlanta VA Regional Office Director implement aplan to ensure staff adhere to Veterans Benefits Administration policyand acknowledge special controlled correspondence with a timely interimor full response.
Inspection of the VA Regional Office, New Orleans, Louisiana
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16-04626-280

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Directorimplement a plan to assess the effectiveness of secondary reviews forSpecial Monthly Compensation and ancillary benefits claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2018
We recommended the Continental District Director implement a plan toensure oversight and prioritization of proposed rating reduction cases forcompletion at the end of the due process time period at the New OrleansVA Regional Office.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2017
We recommended the New Orleans VA Regional Office Director ensureclaims assistants receive all mandatory annual training on claimsestablishment procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Directorimplement a plan to strengthen the review process to assess all elementsrequired when establishing claims in the electronic record.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Directorprovide training to Legal Administrative Specialists responsible forprocessing controlled correspondence and monitor the effectiveness ofthe training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/18/2018
We recommended the New Orleans VA Regional Office Director ensureLegal Administrative Specialists adhere to Veterans Benefits Administration policy when processing special controlled correspondence.
Review of Alleged Delay of Care and Scheduling Issues at the VAMC in West Palm Beach, FL
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15-02583-256

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure recruitment efforts are progressing to fulfill cardiology clinic vacancies and that there are sufficient cardiologists for the needs of the Medical Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure all scheduling staff are trained on the requirement to reschedule appointments canceled by the clinic within 14 days of the original appointment date.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure schedulers are using the clinically indicated or preferred appointment dates when scheduling appointments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2018
We recommended the Director of the West Palm Beach VA Medical Center ensure supervisors perform the required number of scheduling audits for each scheduler as required by VAMC policy.
Audit of VHA's Consolidated Patient Account Center Controls To Prevent Improper Billings for Service-Connected Conditions
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16-00589-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Centers review a statistical sample of bills issued during fiscal years 2015 and 2016 for the treatment of service-connected veterans to identify erroneously billed amounts that require refunds, and use these results to address internal control deficiencies and assess what additional efforts can be taken to identify and refund erroneously billed amounts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to provide billing staff read-only access to the Veterans Benefits Management System to identify potential service-connected bills that require review by Revenue Utilization Review nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management establish oversight procedures to review statistical samples of prescriptions prior to generating bills to veterans and to address any identified systemic or facility-specific billing problems.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise quality assurance reviews to include reviews of pharmacy bills and evaluate whether Revenue Utilization Review nurses correctly validate or make service-connection determinations for veterans’ medical treatment based upon staffing and workload.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise policy and procedure to require Consolidated Patient Account Center staff to adequately provide and document training for VA medical facility staff regarding specific service-connection determination errors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2018
We recommended the Under Secretary for Health require Consolidated Patient Account Center management to track and monitor incorrect medical provider service-connection determinations and coordinate training to ensure identified issues are appropriately addressed.
Review of VA’s Readiness To Implement the Digital Accountability and Transparency Act
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16-02454-250

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Establish milestones to monitor VA’s system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Obtain procurement and grants management system capability that is integrated with the financial system as part of VA’s transition to a shared service provider to the extent feasible.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Improve communication with, and accountability of, administrations and offices and their points of contact who are responsible for providing data and documentation. Accountability should include timely, complete, and accurate submissions to the Project Management Office.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue working with the points of contact to ensure program information for all funds is submitted as required.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Identify internal controls and develop standard operating procedures for the processes used to obtain, extract, classify, and summarize data from VA’s financial and management systems to comply with the DATA Act schema.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: In conjunction with VA’s component organizations, perform an assessment of how business, accounting, and payment processes interact with one another for the purpose of establishing relevant policies and procedures to improve VA’s data quality. This assessment should include VA’s subsidiary systems and their interface status with the general ledger system, that is Financial Management System.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Ensure complete reconciliations are performed between the subsidiary and general ledger systems. Differences should be researched and resolved to improve data quality.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue to work on minimizing the use of the Management Information Exchange to record journal vouchers that are not linked to obligation and expenditure data by object class or program activity, or devise a mechanism to track such information when recording Management Information Exchange journal vouchers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Perform reconciliations between VA’s procurement systems (Electronic Contract Management System and Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system) and Financial Management System to ensure consistency, accuracy, and completeness of financial and procurement data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Provide resources for data storage capabilities to improve auditability of data. Specifically, VA should establish a data storage mechanism such as a shared drive to store data received from points of contact or developed internally by the Project Management Office. Such information should be secured, readily available for analysis and requests, validated, and auditable.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Ensure proper segregation of duties between staff responsible for processing data for submission to the data broker and staff responsible for validating the accuracy and completeness of data prior to submission to the data broker.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Provide necessary resources to the VA DATA Act Project Management Office to ensure that the office can coordinate the data inventory, mapping, and validation for the required DATA Act Schema data elements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Require administration points of contact to respond timely to Project Management Office data requests to ensure that the data elements can be inventoried, mapped, and validated and that gap analyses are performed thoroughly.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Use the data inventory and mapping to support VA’s move to a shared service provider and ensure full compliance with the DATA Act.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Establish procedures for data edits and validations to ensure that DATA Act submissionsare accurate and complete. At a minimum, management should selectively test internalcontrols related to the preparation of data submissions.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Assess the impact of the internal control weaknesses, as reported by VA’s financialstatement audit, on DATA Act data, and develop alternative processes to address data quality issues.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/8/2017
In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer: Continue to maintain communication with the Office of Management and Budget andTreasury regarding VA’s data reporting limitations and progress, and document suchcommunication.
Clinical Assessment Program Review of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
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16-00566-314

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the Quality, Safety, and Value Committee be consistently chaired or co-chaired by the Facility Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2019
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that facility managers ensure carpets and tile floors in patient care areas are clean and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug-to-drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers 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 compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior and a Disruptive Behavior Committee/Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
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.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that clinicians enter orders for mammograms in the Computerized Patient Record System and that clinical managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians screen patients for tetanus vaccinations at clinic visits and that clinical managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2018
We recommended that clinicians document all required vaccine administration elements and that clinical managers monitor compliance.
Healthcare Inspection Veterans Choice Program Dermatology Delays, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
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16-02551-306

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Federal Health Care Center Director ensure that fee department staff take timely action when providers order non-VA care and Choice dermatology consults.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Federal Health Care Center Director ensure that fee department staff take timely action to complete, cancel, or discontinue non-VA care and Choice dermatology consults, as appropriate.
Clinical Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York
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16-00558-311

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that for patients transferred out of the facility, providers consistently include date of transfer and documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that the facility trend the use of reversal agents in moderate sedation cases, that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events, and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2018
We recommended that providers include the history of previous adverse experiences with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that clinical managers ensure employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2017
We recommended that the facility establish a Community Nursing Home Oversight Committee.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility managers ensure clinical visits occur within the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that facility managers ensure all employees receive additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2017
We recommended that the Facility Director immediately remove unauthorized employees’ access to the medication room, evaluate access for all medication rooms within the facility, and take corrective action to meet Veterans Health Administration requirements.
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