All Reports

Inspection of the VA Regional Office Oakland, California
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15-05023-112

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Butler Healthcare, Butler, Pennsylvania
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15-05161-98

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2016
We recommended that clinicians complete Home Telehealth enrollment consults.
No. 6
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the VA Central California Health Care System, Fresno, California
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15-04707-111

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility manager’s monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
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: 7/7/2016
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: 9/26/2016
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, include corrective actions to address those deficiencies, and track corrective actions to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Hospital Epidemiology Committee meeting minutes consistently reflect discussion of identified high-risk areas and implementation of actions to address those areas and document follow-up on actions implemented to address identified problems.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise operating room emergency fire policy and procedures to include alarm activation, evacuation, and equipment shutdown with responsibility for turning off room or zone oxygen.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes visual observation/“hands-on” skill assessment of aseptic technique and gloved fingertip sampling.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that special care unit sending nurses document transfer assessments and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended physicians consistently document discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers review the organizational alignment for the Radiation Safety Officer position to ensure compliance with Veterans Health Administration policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that facility managers develop and implement a comprehensive computed tomography policy that includes a quality control program and procedures to follow when revising computed tomography protocols.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that computed tomography technologists perform and document quality control checks, that a supervisory employee conducts periodic review to verify the checks were done, and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
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. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
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.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Healthcare Inspection – Veterans Crisis Line Caller Response and Quality Assurance Concerns, Canandaigua, New York
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14-03540-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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
Closed and Implemented Recommendation Image, Checkmark
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.
Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming
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15-04697-105

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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 facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2017
We recommended that Physician Utilization Management Advisors 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: 12/14/2016
We recommended that the facility consistently take actions when data analyses indicate problems or opportunities for improvement and evaluate them for effectiveness in committee reviews, utilization management, and root cause analyses and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the facility conduct an annual infection prevention risk assessment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that the facility revise its policy for temporary bed locations to include priority placement for inpatient beds given to patients in temporary bed locations, upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that clinicians consistently place flags in the electronic health records of patients identified as high risk for suicide and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2016
We recommended that clinicians not place flags in the electronic health records of patients identified as moderate or low risk for suicide and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2017
We recommended that clinicians include the identification of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility managers ensure electronic health record quality reviews include a representative sample of charts from each service or program.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that facility managers ensure all non-hospice and palliative care clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility managers establish a process to track and document hospice and palliative care consults that are not acted upon within 7 days of the request.
Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania
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15-04708-115

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
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: 12/19/2016
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: 7/7/2016
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: 7/7/2016
We recommended that the Patient Safety Manager submit an annual patient safety report to facility leaders at the completion of each fiscal year.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the facility revise its protected peer review policy to be consistent with Veterans Health Administration policy and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the Power of Women Embracing Recovery Program have a Class K fire extinguisher available in the kitchen used by residents.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Domiciliary Care for Homeless Veterans Program, Post-Traumatic Stress Disorders Residential Rehabilitation Treatment Program, and Substance Abuse Treatment Unit employees consistently perform and document contraband inspections, daily bed checks, and resident room inspections for unsecured medications and that program/unit managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Domiciliary Care for Homeless Veterans Program and Substance Abuse Treatment Unit managers ensure residents secure medications in their rooms and monitor compliance.
Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas
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15-04696-107

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that controlled substances inspectors consistently reconcile 1 day's dispensing from the pharmacy to each automated unit and that the Controlled Substances Coordinator monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure the Controlled Substances Coordinator's position description includes controlled substances oversight duties.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2016
We recommended that the facility ensure controlled substances inspectors receive annual updates and refresher training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the Controlled Substances Coordinator ensure random scheduling of non-pharmacy area inspections with no distinguishable patterns and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that controlled substances inspectors consistently validate transfers from one storage area to another and that the Controlled Substances Coordinator monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that controlled substances inspectors consistently verify hard copy orders for five randomly selected dispensing activities (or a minimum of two if less than five dispensing activities on the unit) and that the Controlled Substances Coordinator monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that pharmacy employees consistently perform 72-hour inventories of the main vault and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that controlled substances inspectors consistently compare drugs held for destruction with the Destruction File Holding Report for 10 randomly selected drugs and that the Controlled Substances Coordinator monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommended that controlled substances inspectors consistently verify completion of drug destructions at least quarterly and that the Controlled Substances Coordinator monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that clinicians communicate incomplete or probably benign results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that clinicians include the contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Coatesville VA Medical Center, Coatesville, Pennsylvania
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15-05163-106

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2016
We recommended that managers provide auditory privacy for Springfield VA Clinic veterans at check-in.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2016
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2016
We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Alleged Untimely Care at VHA’s Community Based Outpatient Clinic Colorado Springs, CO
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15-02472-46

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the clinically indicated or preferred appointment dates when scheduling primary care patient appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended the Eastern Colorado Health Care System Director ensure that scheduling staff use the earliest appropriate date when scheduling new patient appointments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended the Eastern Colorado Health Care System Director ensure that staff place all veterans with appointments occurring over 30 days after the clinically indicated or preferred appointment date on the Veterans Choice List within 1 day of scheduling the appointment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended the Eastern Colorado Health Care System Director ensure that resources are sufficient for scheduling staff to act on consults within 7 days and appointment requests for newly enrolled veterans within 1 day of the approved appointment request.
Review of Alleged Patient Scheduling Issues at the VA Medical Center in Tampa, FL
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15-03026-101

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended the Director of James A. Haley Veterans’ Hospital coordinate with the responsible contracting officer to develop a mechanism to ensure the facility receives prompt notification of scheduled Veterans Choice Program appointments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital request that the responsible contracting officer determine if Health Net complies with the modification to the Patient-Centered Community Care contract requiring the contractor to notify VA when a veteran is scheduled for an appointment through the Veterans Choice Program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services transmit all scheduling audit results to appropriate staff for awareness and corrective action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital ensure Performance Improvement services develop a procedure to verify the schedulers properly correct identified errors.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/5/2016
We recommended the Director of James A. Haley Veterans’ Hospital ensure supervisors provide additional training to schedulers regarding the management of the Veterans Choice List to ensure staff add all eligible veterans to the Veterans Choice List in a timely manner and that veterans remain on the Veterans Choice List.
Inspection of VA Regional Office Little Rock, Arkansas
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15-04983-86

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/28/2016
We recommended the Little Rock VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania
|
15-04706-104

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semiannually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the Women Veterans Program Manager has sufficient allocated administrative time for oversight duties and does not provide direct patient care more than 1/8 of her time (5 hours per week).
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend that clinicians develop and document Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that domiciliary managers ensure the Domiciliary Care for Homeless Veterans and Substance Abuse Domiciliary has written agreements in place acknowledging resident responsibility for medication security.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Western New York Healthcare System, Buffalo, New York
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15-05155-89

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers monitor hand hygiene compliance at the Buffalo VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers document their consideration and implementation of safety needle devices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure fire drills are conducted at least every 12 months at the Buffalo VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers test the alarm system or panic buttons regularly at the Buffalo VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers maintain a clean environment of care at the Buffalo VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure hand hygiene products are readily accessible to employees at the Buffalo VA Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers provide feminine hygiene products in women’s public restrooms at the Buffalo VA Clinic.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers at the Buffalo VA Clinic ensure all medications are secured from unauthorized access.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers at the Buffalo VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers ensure that PTSD patients receive mental health treatment, when applicable.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas
|
15-05149-88

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that providers sign home telehealth assessments and treatment plans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York
|
15-04698-99

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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)
We recommended that the Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure floors in patient care areas are clean and free of mold and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes a written test and gloved fingertip sampling.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility fully implement the newly revised compounded sterile products safety/competency assessment checklist that includes all required elements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure pharmacy staff remove packaging from items before transfer to the buffer room and clean and sanitize items transferred to the buffer room.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
Combined Assessment Program Follow-Up Review of the VA St. Louis Health Care System, St. Louis, Missouri
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15-00075-87

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility managers ensure access to exits is unrestricted and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2017
We recommended that facility managers ensure all nurse call system alarms are functioning and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility managers ensure emergency response medications and equipment are available for immediate use in patient care areas and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure electrical power strips are not plugged into other power strips and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that facility managers ensure crash carts using electrical power strips have those strips permanently attached.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure patient care areas do not contain portable space heaters and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2017
We recommended that the facility repair or replace the uneven and buckling flooring in the combined Domiciliary and Substance Abuse Residential Rehabilitation Treatment Program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure compliance with Safety Data Sheet recommendations regarding chemical storage, use, and safety.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure signage identifying the location of alternative exits is posted during construction projects.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure signage is installed to clearly identify the location of fire extinguishers in large rooms and those obstructed from view.
Healthcare Inspection – Environment of Care and Safety Concerns in Operating Room Areas, Edward Hines Jr. VA Hospital, Hines, Illinois
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14-05173-92

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Acting Facility Director implement an action plan to remediate water damage in the basement of Building 200.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2016
We recommended that the Acting Facility Director initiate a safety analysis of the current overhead paging and emergency system for communication of a code throughout the entire surgical operating room, including the post anesthesia care units and take action as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Acting Facility Director implement processes to maintain recommended ranges for temperature and humidity in operating room areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Acting Facility Director take actions to prevent staff injury as a result of surgical booms located in operating rooms.
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