All Reports

Community Based Outpatient Clinics Summary Report – Evaluation of Alcohol Use Disorder Care at Community Based Outpatient Clinics and Other Outpatient Clinics
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15-01296-203

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Amarillo VA Health Care System, Amarillo, Texas
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16-00028-337

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the clinic manager ensures the risk of infection is minimized when storing and disposing of medical waste at the Childress VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that the clinic manager ensures that exit routes are unobstructed at the Childress VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that staff at the Childress VA Clinic protect and secure patient-identifiable information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Childress VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2017
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that clinicians consistently provide and document interventions for clinically significant abnormal laboratory results.
Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut
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16-00116-323

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
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: 11/15/2016
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: 4/25/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that facility managers ensure employees follow facility policy for disinfecting exam tables after each patient use and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that facility managers ensure annual competency assessment for pharmacy employees who prepare compounded sterile products includes a written test and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the Suicide Prevention Coordinators consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that nurse managers accurately monitor the nurse staffing methodology implemented in March 2013 and use the standard nursing hours per patient day calculation to assess nurse staffing adequacy for all units.
Healthcare Inspection - Access and Quality of Care Concerns, Phoenix VA Health Care System, Phoenix, Arizona, and Delayed Test Result Notification, Minneapolis VA Health Care System, Minneapolis, Minnesota
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15-03867-287

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to improve Emergency Department access and flow during times of increased demand.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to decrease the number of patients who leave the Emergency Department without being seen by a provider.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director review current verbal communication practices in the Emergency Department and determine what steps are reasonable to safeguard patient information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director assess Emergency Department medication prescription delivery practices to identify potential opportunities to improve pharmacy services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure all patients in the Radiology Department are supervised.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director assess Environmental Management Services staffing needs and take appropriate actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure environment of care concerns identified in this report are corrected and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure Allergy Clinic staff use standard precautions when disposing used thermometer covers and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure patients receive recommended preventive medications or are offered substitutions if the medication is not on the VA National Formulary.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Minneapolis VA Health Care System Director ensure that test results are communicated to patients as required.
Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2015
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16-01040-324

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/1/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Risk Managers invite clinicians involved in Level 2 or 3 peer reviews to submit comments to and/or appear before the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers, ensure Facility Directors review all privilege forms annually and document the review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Medical Staff Coordinators complete the conversion from six-part to two-part credentialing and privileging folders and ensure non-allowed information is not placed in the folders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Chiefs of Surgery discuss surgical deaths with identified problems in Surgical Work Group meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities designate a committee to oversee safe patient handling activities, track patient handling injury data, and share data with safe patient handling champions.
Review of VHA’s Alleged Manipulation of Appointment Cancellations at VAMC Houston, TX
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15-03073-275

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken based on the factual circumstances developed in this report regarding appointments incorrectly recorded as canceled by patient.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken regarding instructions to staff to incorrectly record appointments as canceled by patient.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center provides training on when to use clinic versus patient cancellation options and how to identify the clinically indicated appointment date.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center improves scheduling audit processes to ensure that managers conduct a complete review of appointment data to ensure scheduling staff are using the correct cancellation type and clinically indicated or preferred appointment date.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center makes sure managers take corrective action when audits identify deficiencies in scheduling staff’s use of appointment cancellation type and clinically indicated or preferred appointment dates.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director conduct a scheduling audit within 3 months after Recommendations 3 through 5 are implemented to ensure the corrective actions taken were effective.
Review of VA's Guidance on Protecting Religious Beliefs
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15-03700-283

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs rescind and replace Chapters 6 and 7 from Manual 40-2, National Cemeteries, Administration, Operation, and Maintenance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 1/17/2018
We recommended the Interim Under Secretary for Memorial Affairs recertify or rescind Directive 3170/1, Ceremonies and Special Events at VA National Cemeteries.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs incorporate National Cemetery Administration’s three interim guidance documents into directives or handbooks.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2016
We recommended the Interim Under Secretary for Memorial Affairs develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health recertify or rescind Veterans Health Administration’s three religious belief guidance documents that need to be updated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2017
We recommended the Under Secretary for Health develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health provide staff a means to request senior official assistance, when necessary, to obtain timely agency-level concurrences.
Combined Assessment Program Review of the Amarillo VA Health Care System, Amarillo, Texas
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16-00118-321

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended that the facility set triggers for when a Focused Professional Practice Evaluation for cause would be indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
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: 11/29/2016
We recommended that designated employees follow the facility policy for identification of individuals entering the facility after normal business hours and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that facility managers ensure employees perform and consistently document monthly cleaning of walls and light fixtures in all compounding areas and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that clinicians include contact numbers of family or friends for support and an assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Connecticut Healthcare System, West Haven, Connecticut
|
16-00027-318

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that the Facility Director ensures that fire drills and fire drill critiques are conducted at least every 12 months at the Winsted VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2016
We recommended that the Winsted VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2016
We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Jesse Brown VA Medical Center, Chicago, Illinois
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16-00029-322

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the facility revise the local policy to include specific procedures for the identification of individuals entering the CBOCs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the facility ensure a safe work environment with adequate security coverage and incident responses at the Auburn Gresham VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommend that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2017
We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the facility update its template to ensure providers’ plans of care and disposition are accurately documented for patients with positive PTSD screens.
Combined Assessment Program Review of the Jesse Brown VA Medical Center, Chicago, Illinois
|
16-00121-320

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2017
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: 1/12/2017
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: 7/29/2017
We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that employees wear personal protective equipment and gloves when compounding sterile products in the operating room satellite pharmacy and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that sending nurses document transfer assessments and receiving nurses document transfer notes and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that attending physicians co-sign resident physicians’ discharge notes/instructions and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that the facility review and revise its advance directives policy to ensure it is consistent with Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that employees consistently use appropriate note titles to document screening and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that plans include contact numbers of family or friends for support and assessment of available lethal means and how to keep the environment safe and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2017
We recommended that clinicians perform and document patient assessments following blood product transfusions and that facility managers monitor compliance.
Healthcare Inspection - Alleged Patient Safety Concerns, Miami VA Healthcare System, Miami, Florida
|
14-03183-317

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Community Living Center patients, families, and staff know the circumstances and guidelines under which they should initiate Integrated Ethics consults, have access to the Ethics Consultation Service, and know how to request an ethics consultation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Community Living Center staff receive training regarding suicide risk factors and the importance of documenting and communicating identified suicide risk factors during Interdisciplinary Team meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that system clinical leadership reviews current practices of the ordering and administration of sleeping medications in the Community Living Center to determine if those practices optimize patient safety.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that reviews of incidents involving patient safety are comprehensive and accurately reflect and document all components as outlined in the VHA National Patient Safety Improvement Handbook guidelines.
Healthcare Inspection – Mental Health Service Concerns at the Knoxville VA Outpatient Clinic, James H. Quillen VA Medical Center, Mountain Home, Tennessee
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14-04435-265

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2017
We recommended that the Facility Director improve processes for communicating with community-based consumer-run groups that provide mental health services to veterans enrolled at the Knoxville VA Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Facility Director ensure that the Clinic’s Veterans Justice Outreach Specialist provides comprehensive services including outreach for veterans in the Knox and surrounding counties in accordance with Veterans Health Administration policy.
Combined Assessment Program Summary Report – Evaluation of Coordination of Inpatient Consults in Veterans Health Administration Facilities
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16-01489-311

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinicians consistently include ‘inpatient’ in the inpatient consult title and that facility managers monitor compliance.
Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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16-00111-310

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2017
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: 1/4/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that Environment of Care Board meeting minutes include corrective actions taken to address rounds deficiencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that facility managers ensure medical waste/biohazard containers are properly covered and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that employees date multi-dose medication vials when opened and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that facility managers ensure all sharps containers are closed and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that dental clinic managers ensure all dental clinic employees complete hazard communication training on chemical classification, labeling, and safety data sheets and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended that facility managers ensure consistent monitoring of operating room temperature, humidity, and positive pressure.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that facility managers ensure all operating room exits are unobstructed and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the facility revise the competency assessment policy for employees who prepare compounded sterile products to include the required intervals for gloved fingertip sampling.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the facility revise the compounded sterile products safety/competency assessment checklist to include donning of personal protective equipment in the required order and the performance of appropriate hand hygiene after personal protective equipment removal.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the facility revise its temporary bed locations policy to include priority placement for inpatient beds given to patients in temporary bed locations.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that physicians document transfer notes and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that receiving physicians document transfers and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that a medical physicist complete and document inspections of computed tomography scanners following repair or modifications affecting dose or image quality and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2017
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2017
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2017
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that clinicians include assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2017
We recommended that facility managers ensure the Domiciliary Care for Homeless Veterans Program is clean and monitor compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2017
We recommended that the facility repair or replace identified items in the Domiciliary Care for Homeless Veterans Program.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2017
We recommended that the facility correct the deficiencies identified in the Domiciliary Care for Homeless Veterans Program and that documentation reflects correction.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that facility managers ensure the Domiciliary Care for Homeless Veterans Program has closed circuit television monitors with recording capability in public areas and does not have monitors installed in treatment areas.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that facility managers ensure exit signs on Domiciliary Care for Homeless Veterans Program resident floors are visible.
Administrative Investigation - Alleged Prohibited Personnel Practice, Board of Veterans Appeals, Washington, DC
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15-02747-314

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 Benefits Administration (VBA)
Closure Date: 10/20/2017
We recommend that the VA Deputy Secretary confer with the Offices of General Counsel and Human Resources Management to develop VA policy related to the staffing and recruitment of VLJs, incorporate it into proper guidance and a requirement to sign a confidentiality agreement, provide applicability of the Privacy Act, a clear definition of what is confidential, and ensure that policy is implemented.
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