All Reports

Healthcare Inspection Sterile Compounding Environment and Practices, Overton Brooks VA Medical Center, Shreveport, Louisiana
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17-01542-273

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that facility leaders implement corrective actions and processes to fully comply with United States Pharmacopeia 797> requirements, test the effectiveness of these actions and processes before resuming full compounded sterile preparations operations, and monitor compliance of key elements through a facility or Veterans Integrated Service Network-level committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/14/2017
We recommended that the Veterans Integrated Service Network Director issue guidance to facility staff requiring that results of external reviews be provided to facility leaders as soon as those results are available.
Review of Alleged Unauthorized Commitments for Prosthetic Purchases at VA Network Contracting Office 3
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15-03678-210

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2018
We recommend the Director of Contracting, NCO 2 submit a ratification request for the unauthorized commitments identified in this report to the cognizant Head of Contracting Activity – Executive Director, Service Area Office East.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2017
We recommend the Director of Contracting, NCO 2 submit a ratification request for the unauthorized commitments identified in this report to the cognizant Head of Contracting Activity – Executive Director, Service Area Office East.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2017
We recommend the Executive Director, Service Area Office East conduct a review of Network Contracting Office operations to ensure internal controls, such as segregation of duties, are monitored and enforced.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 457,000.00
Clinical Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia
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16-00569-253

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that facility clinical managers ensure peer reviewers consistently document their evaluation of at least one of the important aspects of care and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2018
We recommended that facility managers ensure information technology network room logs for visitors contain all required information to document access and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2018
We recommended that facility managers ensure ventilation grills and 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: 12/20/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that facility managers ensure ice machines in patient nourishment kitchens are clean and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility develop and implement a policy that addresses anticoagulation management.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility designate a physician anticoagulation program champion.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that providers complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2018
We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that the Patient Safety Manager and/or Risk Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
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. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2018
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that facility clinical managers ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that employees consistently complete diagnostic assessments for patients with a positive alcohol screen and that facility managers monitor compliance.
Review of Alleged Inappropriate Contract Actions Related to VA’s Lease of a Digital Imaging Network-Picture Archival Communication System
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15-04351-188

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/1/2017
We recommended the Deputy Assistant Secretary for Acquisition and Logistics develop procedures to ensure acquisition teams fully comply with the fundamental requirements of the Federal Acquisition Regulation on all Digital Imaging Network-Picture Archival Communication System acquisitions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/23/2018
We recommended the Deputy Assistant Secretary for Acquisition and Logistics ensure adequate oversight reviews are conducted for the Digital Imaging Network-Picture Archival Communication System to ensure contracting officers comply with Department of Defense contract terms to obtain commercial price lists by using the Contractor Price Book Spreadsheet.
Review of Alleged Overpayments for Non-VA Care Made by Florida VA Facilities
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15-01080-208

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended the Under Secretary for Health develop and implement a plan to ensure all non-VA physician-administered drugs (other than orally administered) are paid in accordance with the Code of Federal Regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended the Under Secretary for Health develop a plan for uploading Medicare rates into the Fee Basis Claims System to enable the proper payment of physician-administered drug claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
We recommended the Under Secretary for Health issue bills of collection, as necessary and in accordance with VA policy, to recover physician-administered drug overpayments made by Florida VA facilities.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,200,000.00
Opioid Management Practice Concerns, John J. Pershing VA Medical Center Popular Bluff, Missouri
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16-01077-255

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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 Facility Director develop processes to ensure that the relevant providers complete timely patient evaluations for continued long-term opioid therapy for pain based on clinically significant changes or findings to a patient’s health status.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that reviews of the cases of the identified patients with clinically significant changes are completed and take action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers receive education on the concurrent prescribing of dual short acting opioids and tapering of opioids.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers review Veterans Health Administration recommendations regarding the use of opioid risk stratification tools, such as the Opioid Risk Tool, to identify high-risk patients for longterm opioid therapy for pain.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers order urine drug screening frequency based on risk assessment and complete urine drug screening at least annually.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers consistently use urine drug screening confirmatory testing.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director develop processes that minimize the potential for urine drug screening tampering.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
We recommended that the Facility Director ensure that the relevant providers consistently complete the informed consent process prior to initiating long-term opioid therapy for pain as specified by Veterans Health Administration policy.
Review of Alleged Mismanagement of VA's Human Resources and Administration Contract Funds
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16-00327-209

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/1/2017
We recommended the Acting Assistant Secretary for Human Resources and Administration assign responsibility to an office to assess hosting solution options for the Dashboard Tool.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/7/2018
We recommended the Acting Assistant Secretary for Human Resources and Administration evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool investment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Clinical Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama
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16-00581-239

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility clinical managers 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: 3/30/2018
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2018
We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2018
We recommended that facility managers ensure sharps containers stored for pick-up are secured and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history, observations, signs, symptoms, and preliminary diagnoses and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2017
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2018
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 and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2018
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.
Healthcare Inspection – Alleged Unsafe Blood Transfusion Practices, Battle Creek VA Medical Center, Battle Creek, Michigan
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15-01043-247

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Battle Creek VA Medical Center Director ensure that Battle Creek VA Medical Center managers update the blood transfusion policy to align with AABB blood transfusion guidelines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2017
We recommended that the Battle Creek VA Medical Center Director ensure that providers follow Battle Creek VA Medical Center policy and report all transfusion adverse reactions to the Blood Usage Review Committee for review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Battle Creek VA Medical Center Director ensure that the Transfusion Officer who is appointed to the Blood Usage Review Committee has no conflict of interest between committee and professional responsibilities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that the Battle Creek VA Medical Center Director ensure that for level 2 and level 3 peer reviews, the Peer Review Committee provide recommendations to supervisors of non-punitive and non-disciplinary actions, that supervisors discuss and follow up with providers, and that Peer Review Committee minutes include documentation of actions and of supervisory follow-up as required by the Veterans Health Administration. VA
Review of Alleged Removal of Workload Controls at the VARO in San Juan, PR
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15-05235-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/2/2018
We recommended the San Juan VA Regional Office Director develop and implement a plan to review the 722 End Product 930s that staff removed from its inventory in August and September 2015.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2018
We recommended the San Juan VA Regional Office Director monitor the effectiveness of current plans to manage the End Product 930 workload.
Healthcare Inspection—Patient Deaths, Opioid Prescribing Practices, and Consult Management, VA Greater Los Angeles Healthcare System,
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15-01669-246

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure staff conduct a review of canceled or discontinued cardiology consults to determine if patients suffered harm as a result of inappropriate consult closure and confer with the Office of Chief Counsel regarding disclosure as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2017
We recommended that the System Director ensure system staff comply with current Veterans Health Administration policies regarding consult management.
Healthcare Inspection – Delays in the Evaluation and Care of a Patient with Lung Cancer, VA Southern Nevada Health Care System, Las Vegas, NV
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15-01301-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure that providers address and communicate test results to patients within the timeframe required by the Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure that providers timely follow up on non-VA providers’ recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure the Non-VA Medical Care Coordination requirement for patients to be seen by system physicians first for services offered at the system before a Non-VA Medical Care Coordination request is authorized does not delay care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure Non-VA Medical Care Coordination staff process requests according to the urgency noted by the requesting provider.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure Emergency Department providers follow Non-VA Medical Care Coordination consult request processes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure that Non-VA Medical Care Coordination staff are knowledgeable of specific services that are authorized when Non-VA Medical Care Consults are approved.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director review existing practices for filling nonformulary/restricted medications to ensure that medications are ordered, reviewed, and processed timely.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director evaluate patient experiences regarding contracted companies’ processes for delivery of medications and take appropriate corrective actions if needed.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the System Director ensure the peer review process is conducted according to current Veterans Health Administration guidance.
Healthcare Inspection – Nutrition and Food Service Environment of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois
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16-03302-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director complete an analysis of the basement and sub-basement structures to determine if adequate measures are in place to prevent water infiltration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the Facility Director ensure that Nutrition and Food Service kitchen staffing is sufficient to perform all required duties including cleaning and sanitation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2017
We recommended that the Facility Director complete an analysis of the feasibility of relocating the main kitchen to an area that limits the environmental conditions for pests.
Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities
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16-03808-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Suicide Prevention Coordinators provide at least five outreach activities per month and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete Suicide Prevention Safety Plans for all high-risk patients, include in the plans the contact numbers of family or friends for support, and give the patient and/or caregiver a copy of the plan, and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians, in consultation with Suicide Prevention Coordinators, identify inpatients as at high risk for suicide, they place Patient Record Flags in the patients' electronic health records and notify the Suicide Prevention Coordinator of each patient's admission, and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that a Suicide Prevention Coordinator or mental health provider evaluates inpatients identified as at high risk for suicide at least four times during the first 30 days after discharge, and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians identify outpatients as at high risk for suicide, they review the Patient Record Flags every 90 days and document the review and their justification for continuing or discontinuing the Patient Record Flags, and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete suicide risk management training within 90 days of hire and that facility managers monitor compliance.
Healthcare Inspection – Quality of Care Concerns of a Surgical Patient, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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15-04516-229

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2017
We recommended that the System Director ensure a peer review is conducted of this case to determine whether the risk of alcohol withdrawal was adequately assessed prior to the patient’s aortofemoral bypass graft surgery in 2015 and whether this patient’s inpatient medical management, including the complications presented by the patient’s prolonged alcohol withdrawal, was reasonable.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2017
We recommended that the System Director modify the system’s restraint policy to include leadership notification of patients in medical restraints after a specified timeframe in restraints.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2017
We recommended that the System Director ensure wound care documentation is consistent with system policy and monitor compliance.
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