Date Issued
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Report Number
14-02890-120
All Reports
Date Issued
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Report Number
14-02890-134
Date Issued
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Report Number
14-02890-124
Date Issued
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Report Number
14-02890-136
Date Issued
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Report Number
14-03403-128
Date Issued
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Report Number
14-02890-143
Date Issued
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Report Number
14-02890-121
Date Issued
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Report Number
14-02890-135
Date Issued
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Report Number
14-02890-133
Date Issued
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Report Number
14-02890-151
Date Issued
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Report Number
14-02384-45
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2017
We recommended the Acting Under Secretary for Benefits evaluate options for electronically capturing and analyzing information contained on completed Disability Benefits Questionnaires and implement the most cost effective option. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Acting Under Secretary for Benefits revise the remaining 59 public-use Disability Benefits Questionnaires to provide veterans and clinicians adequate notification regarding verification of submitted information.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 7/14/2016
We recommended the Acting Under Secretary for Benefits establish policies and procedures for determining if clinicians who prepare public-use Disability Benefits Questionnaires are private or Veterans Health Administration clinicians.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/2/2018
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include steps for obtaining missing public-use Disability Benefits Questionnaires clinician information and verifying clinicians have an active medical license. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2016
We recommended the Acting Under Secretary for Benefits revise Veterans Affairs Regional Office quality assurance review methodologies to review appropriate samples of claims including public-use Disability Benefits Questionnaires.
No. 6
to Veterans Benefits Administration (VBA)
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with Disability Benefits Questionnaires’ special-issue indicator requirements.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 5/4/2016
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with public-use Disability Benefits Questionnaires’ clinician information completeness requirements.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 7/26/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 9
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 10
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2017
We recommended the Acting Under Secretary for Benefits require Veterans Benefits Administration’s Compensation Service Disability Examination Management staff to conduct annual validation reviews that select samples from a complete universe of claims with public-use Disability Benefits Questionnaires and focus on public-use Disability Benefits Questionnaires that pose an increased risk of fraud. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 11
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include follow-up actions for inadequate public-use Disability Benefits Questionnaires.
No. 12
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise the Systematic Technical Accuracy Review checklists and local quality assurance reviews to evaluate whether claims processors use adequate public-use Disability Benefits Questionnaires instead of obtaining unnecessary Veterans Health Administration compensation and pension examinations.
No. 13
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
No. 14
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 24,000,000.00
Date Issued
|
Report Number
15-04700-119
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/30/2017
We recommended that designated employees maintain a log of individuals entering the facility between 9:00 p.m. and 5:00 a.m. and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms or post signage indicating that rooms are not operational and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/9/2017
We recommended that employees secure sensitive patient information at all times and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes an annual written test.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that facility managers ensure completion and documentation of periodic surface sampling in all required areas and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure employees perform and document monthly cleaning of ceilings, walls, and storage shelving in all compounding areas and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that the facility develop and implement a policy that addresses temporary bed locations.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that the facility revise the computed tomography quality control program to include monitoring by a medical physicist at least annually, image quality monitoring, and computed tomography scanner maintenance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
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. 11
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Date Issued
|
Report Number
15-05164-139
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Pocomoke City VA Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/13/2017
We recommended that the clinic manager reviews the Pocomoke City VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/13/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director ensures that the facility’s written policy include the communication of lab results to patients no later than 14 days from the date on which the results are available to the ordering practitioner.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Date Issued
|
Report Number
15-05497-132
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
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
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
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
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that Environment of Care Committee meeting minutes reflect sufficient discussion of environment of care rounds deficiencies, corrective actions taken to address the deficiencies, and tracking of actions to closure for the three campuses and for the community based outpatient clinics.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that Acute Care and Non-Acute Care Infection Control Committee meeting minutes consistently reflect discussion of hand hygiene data, actions implemented, and follow-up on actions implemented for the three campuses.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure all health care occupancy buildings at the Baltimore and Loch Raven campuses have at least one fire drill per shift per quarter and have documented fire drill critiques and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that facility managers ensure the locked mental health unit and public bathrooms on the 3rd, 5th, and 6th floors at the Baltimore campus are frequently and thoroughly cleaned and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/30/2017
We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms at the Baltimore and Perry Point campuses and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that employees at all three campuses promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure the Baltimore campus Emergency Department main entrance door is functional and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that dental clinic managers ensure all Baltimore campus dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that dental clinic managers ensure all Baltimore campus dental clinic employees complete hazard communication training on chemical classification, labeling, and Safety Data Sheets and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that dental clinic managers ensure designated Baltimore campus dental clinic employees complete laser safety training and monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility managers ensure operating room housekeepers complete training on cleaning and disinfection procedures.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that facility managers ensure consistent monitoring of operating room temperature and humidity and monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that facility managers ensure completion and documentation of periodic surface sampling in the inpatient pharmacy area and monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure the airflow monitoring system alarms in the compounded sterile product ante area are functional.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that facility managers ensure employees perform and document routine cleaning of laminar flow hoods, counters, floors, and storage shelving in the compounding area and monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that attending physicians consistently document a separate admission note or addendum within 1 day of the patient’s admission.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that physicians document transfer notes and that facility managers monitor compliance.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that employees consistently scan the most current advance directive into the electronic health record and that facility managers monitor compliance.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
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. 24
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
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. 25
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that clinicians include the identification of contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 26
to Veterans Health Administration (VHA)
Closure Date: 1/3/2017
We recommended that clinicians ensure patients and/or family members receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Date Issued
|
Report Number
15-02413-55
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended the Veterans Integrated Service Network 18 Director ensure the Southern Arizona VA Health Care System develop and implement a policy requiring coordination and review of leased equipment requests with the Health Care System's support services during the acquisition process.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 217,000.00
Date Issued
|
Report Number
15-05024-97
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 7/22/2016
We recommended the Manila VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Date Issued
|
Report Number
14-03540-123
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that issues regarding response hold times when callers are routed to backup crisis centers are addressed and that data is collected, analyzed, tracked, and trended on an ongoing basis to identify system issues.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that orientation and ongoing training for all Veterans Crisis Line staff is completed and documented.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that silent monitoring frequency meets the Veterans Crisis Line and American Association of Suicidology requirements and that compliance is monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the Office of Mental Health Operations Executive Director establish a formal quality assurance process, as required by the Veterans Health Administration, to identify system issues by collecting, analyzing, tracking, and trending data from the Veterans Crisis Line routing system and backup centers and that subsequent actions are implemented and tracked to resolution.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director consider the development of a Veterans Health Administration directive or handbook for the Veterans Crisis Line.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/31/2017
We recommended that the Office of Mental Health Operations Executive Director ensure that contractual arrangements concerning the Veterans Crisis Line include specific language regarding training compliance, supervision, comprehensiveness of information provided in contact and disposition emails, and quality assurance tasks.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/26/2017
We recommended that the Office of Mental Health Operations Executive Director consider the development of algorithms or progressive situation-specific stepwise processes to provide guidance in the rescue process.
Date Issued
|
Report Number
15-05162-93
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/29/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Date Issued
|
Report Number
15-05023-112
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/27/2016
We recommended the Oakland VA Regional Office Director conduct a review of the 58 temporary 100 percent disability evaluations remaining from the inspection universe of 88, and take appropriate action.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/27/2016
We recommended the Oakland VA Regional Office Director implement a plan to ensure all claims processing staff comply with the Veterans Benefits Administration’s second-signature policy for higher levels of special monthly compensation claims.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/27/2016
We recommended that the Acting Under Secretary for Benefits ensure that approved higher levels of special monthly compensation training materials are updated and accurate
Date Issued
|
Report Number
15-05161-98
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that employees at the Cranberry Township VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that managers ensure that staff at the Cranberry Township VA Clinic participate in emergency management training and exercises.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that managers ensure that Cranberry Township VA Clinic employees receive the required hazardous communications training.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that managers at the Cranberry Township VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians complete Home Telehealth enrollment consults.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.