All Reports

Healthcare Inspection—Environment of Care and Other Quality Concerns, Cincinnati VA Medical Center, Cincinnati, Ohio
|
16-02094-219

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2017
We recommended that the Facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.
Healthcare Inspection – Community Nursing Home Program Safety Concerns, VA Northern California Healthcare System, Mather, California
|
15-01325-205

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director ensure that program staff coordinate mental health appointments, including verifying the necessity, between facility providers and assigned community nursing home physicians prior to scheduling.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that the Facility Director ensure clinical staff report suspected elder abuse within the required timeframe and document the reporting in the patient’s electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2017
We recommended that the Facility Director ensure Non-VA Care Coordination staff timely deliver authorizations for consulted services to contracted community nursing home staff and that facility scheduling staff recognize when patients reside in a community nursing home and coordinate appointments with program or contracted community nursing home staff to ensure timely response to consults.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director require program registered nurses and social workers consistently conduct monthly or quarterly follow-up visits and ensure timely resolution of patient care needs identified in these visits.
Clinical Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania
|
16-00571-207

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data twice a year and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers ensure peer reviewers consistently document their use 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: 11/17/2017
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: 8/23/2017
We recommended that the Patient Safety Manager 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: 8/23/2017
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2017
We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
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: 11/17/2017
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 and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that Residential Recovery Center employees perform and document contraband inspections and rounds of public spaces and that managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.
Healthcare Inspection – Follow-Up Review of Management of Mental Health Consults and Other Access to Care Concerns, VA Maine Healthcare System, Augusta, Maine
|
16-00354-201

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2017
We recommended the System Director ensure Mental Health schedulers consistently make direct contact with patients prior to scheduling appointments and that compliance is monitored for a minimum of three months.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2017
We recommended the System Director ensure training and competencies are documented, complete, and up to date for all staff responsible for scheduling Mental Health appointments.
Clinical Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa
|
16-00564-170

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
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: 8/3/2018
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that Environment of Care Council 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: 9/21/2017
We recommended that facility managers ensure fire extinguisher locations are clearly identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure information technology network room visitor logs contain all the required elements and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that employees store expired medications separately from medications available for administration and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure standard operating procedures for the bronchoscope are consistent with the manufacturer's instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2018
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2018
We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that providers perform history and physical examinations within 30 calendar days prior to the moderate sedation procedure and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2018
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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the facility correct the deficiencies identified for the Mental Health Residential Rehabilitation Treatment Program and that documentation reflects correction actions taken.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that facility managers ensure the review of the hazardous materials inventory at the Marshalltown CBOC occurs twice within a 12-month period.
Clinical Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida
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16-00565-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
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: 9/19/2017
We recommended that facility managers implement the use of a visitors log during non-business hours and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the facility perform quality control testing on all endoscopes and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the facility review quality assurance data for the anticoagulation management program quarterly as defined by local policy and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2017
We recommended that for patients transferred out of the facility, transferring providers consistently include documentation of patient or surrogate informed consent, VA Form 10-2649B, in transfer documentation and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that providers consistently complete VA Form 10-2649A for patients transferred out of the facility and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
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 and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Program employees at Lake Baldwin conduct and document daily bed checks and that program managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2017
We recommended that facility managers ensure all Mental Health Residential Rehabilitation Treatment Program emergency exit door alarms are functional and turned on at all times and that program managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2018
We recommended that facility managers ensure all closed circuit television monitoring cameras at the Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Programs have recording capability and that program managers monitor compliance.
Interim Summary Report - Healthcare Inspection - Patient Safety Concerns at the Washington DC VA Medical Center, Washington, DC
|
17-02644-202

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health take immediate action to ensure that necessary supplies and equipment are available in patient care areas at the Washington DC, VA Medical Center.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health take immediate action to implement an effective inventory management system throughout the Washington DC, VA Medical Center.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health take immediate action to ensure that current stock at the Washington DC, VA Medical Center does not include recalled equipment or supplies.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health take all appropriate steps to ensure that the environmental integrity of the sterile satellite storage areas complies with VA policy.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health take immediate action to create an inventory and establish accountability over the equipment and supplies in the off-site warehouse.
No. 6
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health take all appropriate steps to ensure that the Washington DC, VA Medical Center and Veterans Integrated Service Network arrange the orderly movement of goods and supplies from the warehouse that minimizes losses to the Government.
No. 7
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health deploy additional logistics staff with in-depth Generic Inventory Package experience to the Washington DC, VA Medical Center until reasonable assurances can be provided that existing logistics staff can maintain an effective inventory management system.
No. 8
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended the Under Secretary for Health expedite hiring of permanent positions at the Washington DC, VA Medical Center, to include the Associate VA Medical Center Director, the Nurse Executive, the Chief of Logistics, Assistant Chief of Logistics, and supply technicians.
Healthcare Inspection – Peer Review for Quality Management Concerns, Huntington VA Medical Center, Huntington, West Virginia
|
15-00223-196

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that peer reviewers identify and evaluate surgical and non-surgical clinical events [redacted pursuant to 38 U.S.C. § 5705].
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director maintain full compliance with the Veterans Health Administration’s peer review directive when service-level committees conduct initial peer reviews and consider ensuring secondary review of all such cases [redacted pursuant to 38 U.S.C. § 5705].
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that the Peer Review Committee provides final Level of Care assignments in writing for all cases brought before it.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that service chiefs select peer reviewers to conduct initial peer reviews and that protected peer review processes provide means for peer reviewers to withdraw when uncomfortable about conducting reviews.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director ensure that initial peer reviewers possess the qualifications required of peers relative to the episodes of care under review.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2017
We recommended that the Facility Director review all cases [redacted pursuant to 38 U.S.C. § 5705]. and repeat the initial peer review process for those cases not conducted in compliance with the Veterans Health Administration’s peer review directive.
Evaluation of Computed Tomography Radiation Monitoring in Veterans Health Administration Facilities
|
16-03920-197

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure a medical physicist inspects computed tomography scanners after completion of repairs or modifications that affect the dose or image quality prior to returning the scanners to clinical service.
Review of Unauthorized System Interconnection at the VA Regional Office in Wichita, Kansas
|
16-00376-133

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/6/2017
We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 8/15/2017
We recommended the Assistant Secretary for Information and Technology implement review processes to monitor the performance of the facility chief information officers, information security officers, and technical staff on the identification of external system interconnections and the required change control processes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/6/2017
We recommended the Assistant Secretary for Information and Technology, in conjunction with the Wichita VA Regional Office Director, ensure that VA's system interconnection with the Kansas Commission on Veterans Affairs Office is brought into compliance with VA Information Security requirements and is authorized by an Interconnection Security Agreement and Facility Compliance Report.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 8/15/2017
We recommended the Assistant Secretary for Information and Technology conduct an annual review of all Veterans Service Organization systems connected to VA¿s network and ensure that appropriate Interconnection Service Agreements are in place and enforced for those connections.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/6/2017
We recommended the Assistant Secretary for Information Technology implement improved change management controls to prevent the establishment of Virtual Private Network concurrent network connections that are not in accordance with VA policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/27/2017
We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
Clinical Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah
|
16-00572-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
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: 8/10/2017
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, the specific deficiencies, corrective actions taken to address identified deficiencies, and resolutions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that facility managers ensure attendance is documented for all fire drills.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that facility managers ensure fire drills have documented critiques.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that facility managers ensure eye protection equipment is readily available for employees.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that facility managers ensure standard operating procedures for the colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with manufacturer instructions for use.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training at orientation for the types of reusable medical equipment they reprocess.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the facility consistently review and report all quality assurance data measures for the anticoagulation management program quarterly and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the facility monitor and evaluate patient transfers as part of the quality management program.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure employees who perform point-of-care glucose testing comply with facility policy for managing critical glucose values.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that providers include history of previous adverse experience with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts using a checklist prior to moderate sedation procedures and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
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 and monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Patient Safety Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
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 Quality of Care Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California
|
15-04976-191

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2019
We recommended that the System Director ensure that nursing staff comply with pressure ulcer documentation requirements and physician providers routinely document participation in the interdisciplinary plan for patients with pressure ulcers.
Audit of VHA's Patient Advocacy Program
|
15-05379-146

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health update patient advocate policies and procedures to ensure they meet current needs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health develop procedures to ensure pertinent program information is recorded in a standardized format in the Patient Advocate Tracking System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2018
We recommended the Under Secretary for Health ensure responsible officials and staff perform patient complaint processing activities in accordance with policies and procedures, such as assuring required program information is recorded and trended at the local and national level.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health work with the Assistant Secretary for Information and Technology to ensure its Patient Advocate Tracking System meets current program requirements for efficient complaint processing and reporting.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
We recommended the Under Secretary for Health establish controls to ensure that patient advocate staffing levels are sufficient to support patient advocate workload estimates.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2017
We recommended the Under Secretary for Health provide patient advocates with periodic formal documented training concerning their responsibilities and utilizing the Patient Advocate Tracking System.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to the Patient Advocate Tracking System are regularly reviewed and extended based upon specific job duties and the need to know.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 9/19/2017
We recommended the Assistant Secretary for Information and Technology work with the Under Secretary for Health to fully assess the Patient Advocate Tracking System security and operational risks and to initiate appropriate corrective actions, including requesting the authority to operate the Patient Advocate Tracking System, if appropriate.
Evaluation of the Quality, Safety, and Value Program in Veterans Health Administration Facilities Fiscal Year 2016
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16-03743-193

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: 10/29/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.
Review of Alleged Use of Incorrect Effective Dates at VBA's VARO in Chicago, IL
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16-02806-182

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 Benefits Administration (VBA)
Closure Date: 3/31/2017
We recommended the Chicago VA Regional Office Director conduct a review of the 586 claims with intent to files remaining from our universe, completed from October 1, 2015 through March 31, 2016, and take appropriate actions and report results back to OIG.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/31/2017
We recommended the Chicago VA Regional Office Director implement a plan to ensure sufficient analysis of quality reviews is completed to identify effective date errors related to intent to files.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/31/2017
We recommended the Chicago VA Regional Office Director ensure claims processors receive training on how to identify intent to files.
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