All Reports

Healthcare Inspection – Alleged Unsafe Patient Transportation Practices, VA Hudson Valley Health Care System, Montrose, New York
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15-02217-85

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that the Director, VA Hudson Valley Health Care System consult with VA NY/NJ Healthcare Network leadership and Regional Counsel regarding the acceptability of shuttle bus drivers’ use of the Passenger Fitness Criteria card.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Chalmers P. Wylie Ambulatory Care Center, Columbus, Ohio
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15-05151-81

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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 managers develop and implement a policy that requires the Grove City VA Clinic staff to receive regular information on their responsibilities in emergency response operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians document verbal informed consent for Home Telehealth services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
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: 8/25/2016
We recommended that the facility director ensure 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: 6/11/2018
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2018
We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Audit of VHA’s Non-VA Medical Care Obligations
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14-02465-47

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health improve cost estimation tools to ensure adequate Non-VA Care cost estimates are produced consistently.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2016
We recommended that the Under Secretary for Health implement a mechanism to ensure that VA medical facilities perform ongoing reviews and adjust cost estimates for individual authorized services to better reflect actual costs.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health update Fee Basis Claims System software to ensure inpatient authorizations can be periodically adjusted when the scope of patient care is fully known.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that the Under Secretary for Health update Fee Basis Claims System software to allow the system to automatically deobligate unused funds when Non-VA Care staff indicate payments for the authorized services are complete.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2016
We recommended that the Under Secretary for Health implement a mechanism to monitor how effectively VA medical facilities are estimating Non-VA Care obligations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 358,000,000.00
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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15-05148-75

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that managers test the panic buttons regularly at the Victor J. Saracini VA Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Victor J. Saracini VA Outpatient Clinic to the parent facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that managers provide feminine hygiene disposal bins in women’s public restrooms at the Victor J. Saracini VA Outpatient Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edward Hines, Jr. VA Hospital, Hines, Illinois
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15-05158-74

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff at the Joliet VA Clinic position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
Follow Up Review on the Mismanagement of Informal Claims Processing at the VA Regional Office Oakland, California
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14-03981-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/12/2016
We recommended the Oakland VA Regional Office Director provide training to the Quality Review Team, Decision Review Officers and Rating Veterans Service Representatives on proper informal claims processing procedures for communications received from service organizations, attorneys, or agents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/15/2016
We recommended the VA Regional Office Oakland Director conduct a complete review of the additional list of 690 claims that may be informal claims, take appropriate actions, and provide certification of completion of the review to the Office of Inspector General.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/23/2017
We recommended the VA Regional Office Oakland Director conduct another review of the remaining 1,248 informal claims and provide certification of completion of the review to the Office of Inspector General.
Review of Alleged Supervisory Influence To Expedite a Friend’s Disability Claim at VA Regional Office New York, New York
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14-04302-12

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2016
We recommended the Director of the New York VA Regional Office take actions, as appropriate, to ensure similar incidents involving expediting friends’ disability claims do not occur in the future.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2016
We recommended the Director of the New York VA Regional Office develop and implement a mechanism to ensure staff have a venue for reporting violations of ethical standards of conduct in the future, should any occur.
Review of Alleged Problems With VBA’s Veterans Benefits Management System and Claims Processing
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14-04816-72

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/8/2016
We recommended the Under Secretary for Benefits ensure that the St. Petersburg VA Regional Office is consistently organizing and mailing hard copy veteran material to contractor scanning facilities and hold the Regional Office Director accountable for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/9/2016
We recommended the Under Secretary for Benefits initiate onsite reviews of the CACI contractor scanning facilities to ensure the timely processing and the proper storage of VA sensitive information at those facilities.
Healthcare Inspection – Poor Follow-Up Care and Incomplete Assessment of Disability, VA San Diego Healthcare System San Diego, California
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15-00827-68

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the Under Secretary for Health ensure that Compensation & Pension examiners document that patients with new diagnoses are counseled on the need for follow up care and provided assistance in obtaining VA care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Under Secretary for Health develop guidance on what clinical information from secure messaging and My HealtheVet must be documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the System Director implement processes to ensure that providers adhere to the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, including follow up assessment at appropriate intervals, when treating patients with chronic opioid therapy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2016
We recommended that the System Director confer with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2016
We recommended that the VA Regional Office San Diego Director review a sample of the specific rater’s work and determine whether failure to obtain relevant service treatment records is a systemic issue with this rater when making compensation claim decisions.
Healthcare Inspection – Eye Care Concerns, Eastern Kansas Health Care System, Topeka and Leavenworth, Kansas
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15-00268-66

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director ensure all system staff use only approved wait lists for scheduling cataract surgeries as required by Veterans Health Administration Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, June 2010.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director ensure that providers use the consultation package in the Computerized Patient Records System for all eye care referrals as required by VHA Handbook 1121.01, VHA Eye Care, March 10, 2011.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director take actions to increase ophthalmologists’ productivity.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Eastern Kansas Health Care System Director explore and implement measures to improve communication, interpersonal dynamics, and operations within and between both Eye Clinics.
Combined Assessment Program Review of the Royal C. Johnson Veterans Memorial Medical Center, Sioux Falls, South Dakota
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15-04699-65

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2015
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
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.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Louis A. Johnson VA Medical Center, Clarksburg, West Virginia
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15-00178-56

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that staff protect patient-identifiable information on laboratory specimens at the Monongalia County VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that the information technology server closet at the Monongalia County VA Clinic 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: 4/20/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
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15-00614-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that credentialing and privileging folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas are clean and bathrooms are free from offensive odors and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers initiate corrective actions to repair the ceiling leak in the operating room supply area.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees secure sensitive patient information at all times and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility annually review the look-alike and sound-alike medication list.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a written policy for the safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that consultants consistently link consult responses to the requests and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
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