All Reports

Inspection of VA Regional Office Hartford, CT
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15-04986-42

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2015
We recommended the Hartford VA Regional Office Director conduct a review of the three temporary 100 percent disability evaluations remaining from our inspection universe as of August 11, 2015, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2016
We recommended the Hartford VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Salem VA Medical Center, Salem, Virginia
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15-00181-53

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2016
We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Charles George VA Medical Center, Asheville, North Carolina
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15-00175-50

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended 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: 3/28/2016
We recommended that providers 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: 3/28/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that the Facility Director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Review of Alleged Beneficiary Travel Irregularities at Hudson Valley HCS, Hampton & Lexington VAMCs
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15-02400-524

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System complies with VHA Procedure Guide requirements to use the Beneficiary Travel Dashboard to calculate mileage as the basis for reimbursement.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System’s and the Hampton Veterans Affairs Medical Center’s Beneficiary Travel Dashboards are configured to assist staff in identifying the nearest facility able to provide care or services as the basis for mileage reimbursements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers strengthen Beneficiary Travel Program processing accuracy by developing a formal plan to routinely identify staff training needs and provide appropriate training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health ensures the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers develop and implement a formal process to routinely identify Beneficiary Travel Program mileage reimbursement processing deficiencies and apply corrective actions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Under Secretary for Health requires the Hudson Valley Health Care System and the Hampton and Lexington Veterans Affairs Medical Centers to determine whether the improper payments identified by our review warrant establishing bills of collection or reimbursing beneficiaries, when applicable.
Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia
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15-00628-49

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Critical Care Committee continue the recently implemented process that includes screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that damaged wheelchairs are repaired or removed from service and that wheelchairs are included in the facility’s preventative maintenance program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that employees follow facility policy for disinfection of non-critical equipment between patients and that exam rooms contain adequate supplies for disinfection.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient-specific insulin vials distributed to units are consistently labeled with correct expiration dates and monitor compliance.
No. 8
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that surgical intensive care unit nurses have 12-lead electrocardiogram and post-anesthesia care competency assessment and validation included in their competency checklists.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that initial clinician emergency airway management competency assessment includes all required subject matter content elements and evidence of a completed written test and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on airway simulators or mannequins and evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and successful demonstration of all required procedural skills on airway simulators or mannequins and that facility managers monitor compliance.
Combined Assessment Program Summary Report – Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities
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15-03804-38

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently conduct initial magnetic resonance imaging patient safety screenings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel consistently document when they review the second magnetic resonance imaging patient safety screening forms.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Level 2 magnetic resonance imaging personnel document resolution of all identified potential contraindications prior to the magnetic resonance imaging exam.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities routinely conduct contrast reaction drills in magnetic resonance imaging areas.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that all designated Level 1 ancillary employees receive annual level-specific magnetic resonance imaging safety training.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
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15-00157-39

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Stillwater VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2016
We recommended that signage is installed at the Stillwater VA Clinic to clearly identify the location of the fire extinguisher in the lobby area.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinic staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Stillwater VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
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: 8/15/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and 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: 8/15/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Combined Assessment Program Summary Report – Evaluation of Acute Ischemic Stroke Care in Veterans Health Administration Facilities
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15-03803-26

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2016
We recommended that the Under Secretary for Health improve the availability of expertise in stroke treatment across the system.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure compliance with stroke care requirements, including prompt and thorough assessment, treatment, and patient education, and ensure the gathering and reporting of required stroke data elements.
Healthcare Inspection – Quality of Care Concerns at a Residential Rehabilitation Treatment Program, VA Maryland HCS, Baltimore, MD
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14-01910-459

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program medical providers document pertinent information related to medical decision-making in the electronic health record and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program managers review and address medical provider staffing needs in the Mental Health Residential Rehabilitation Treatment Program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2016
We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program staff complete all required elements of the safe medication management program.
Healthcare Inspection – Point of Care Testing Program Concerns, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
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14-02576-40

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director ensure that point of care testing policies related to proper identification of patients and test operators comply with Veterans Health Administration requirements including all accreditation and regulatory standards incorporated in these requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director enforce point of care testing policies to include the management process to track issues of error and system misuse and follow them to resolution.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director ensure that all users of point of care testing equipment complete orientation and ongoing training and competency assessments in accordance with facility and Veterans Health Administration policy, to include contract employees and students.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2015
We recommended that the Facility Director evaluate circumstances when sharing or misuse of barcode identifiers became an ongoing practice, in violation of policy, and confer with the Office of Human Resources and the Office of General Counsel to determine appropriate administrative action, if any.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Southern Nevada Healthcare System, North Las Vegas, Nevada
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15-00179-34

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that staff protect patient identifiable information on laboratory specimens during transport from the Southeast VA Clinic to the parent facility or contracted processing facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended that panic alarm testing documentation includes specific testing locations at the Southeast VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended that managers at the Southeast VA Clinic maintain attendance records to verify staff participation during emergency management training and exercises.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that clinicians document in the electronic health record all attempts to communicate laboratory results with the patients.
Combined Assessment Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada
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15-00625-37

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management receive the appropriate training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
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 and specifics, including the deficiency, location, action, and resolution and any trends.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that facility managers monitor the use of clean biohazard bags to ensure they are used appropriately.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility managers ensure designated employees receive emergency evacuation device training and competency assessment and revise the local policy to define expectations for competency assessment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and on the intensive care-step down unit and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that the facility revise the local policy to address advance directive notification, screening, and discussions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that Radiology Service revise its policies to require a 30-minute on-call reporting time for computed tomography scans and a 30-minute on-call response time for radiology interpretation.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the facility ensure clinicians complete all required emergency airway management competency reassessment elements prior to providing emergency airway management coverage and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended that the facility have appropriate emergency airway management coverage during all hours the facility provides patient care and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2016
We recommended that facility managers ensure that identified deficiencies from the annual pharmacy physical security survey are corrected and monitor compliance.
Combined Assessment Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia
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15-00624-31

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that Intensive Care Unit Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code and that the committee documents the reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that the Surgical Work Group meet monthly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that the Safe Patient Handling Committee gather, track, and share patient handling injury data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2016
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that facility managers ensure that employees on the medical-surgical and intensive care units and in the Emergency Department have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that facility managers ensure that intensive care unit employees have post-anesthesia care competency assessment and validation completed and documented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that the facility ensure emergency airway management competency is completed at the time of initial privileges and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that the facility ensure clinicians complete all required competency elements prior to the granting or renewal of privileges or scope of practice and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of John J. Pershing VA Medical Center, Poplar Bluff, Missouri
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15-00142-35

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Pocahontas VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that safety data sheets are current at the Pocahontas VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the Pocahontas VA Clinic is maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that practitioners document a relevant history of the illness or injury and physical findings when the patients are first admitted for VA outpatient care.
No. 10
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.
Healthcare Inspection – Access and Oversight Concerns for Home Health Services, Washington DC VA Medical Center, Washington, District of Columbia
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14-03823-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended that the Under Secretary for Health require facilities to developaction plans to address the care needs of patients on home health services electronic wait lists.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility Director ensure that staff comply with all elementsof national and local policies regarding quality of care, communication, and documentation related to purchased home and community based services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2016
We recommended that the Facility Director ensure that oversight and managementof purchased home and community based services is adequate and in compliance with Veterans Health Administration policies.
Audit of the Seismic Safety of VA’s Facilities
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14-04756-32

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/2/2017
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction establish policy requiring medical facilities to conduct detailed seismic studies for all critical and essential buildings located in high and very high seismic zones that have not already undergone detailed seismic studies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to require Facility Condition Assessment contractors to review structural design documents for buildings that have completed seismic retrofit projects.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction revise its Facility Condition Assessment guidance to ensure conditions of seismically unsafe buildings are properly reported on assessment reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
We recommended the Under Secretary for Health ensure medical facilities submit construction project applications, in a timely manner, for all identified seismically unsafe structural and nonstructural deficiencies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure that Facility Condition Assessment contractors include specific and detailed descriptions of nonstructural seismic deficiencies in their assessments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/21/2016
We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2016
We recommended the Under Secretary for Health ensure its contracting officers obtain copies of seismic certificates or plans to mitigate seismic deficiencies from lessors prior to executing lease agreements or renewals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/2/2017
We recommended the Acting Assistant Secretary for Management revise VA Directive 7415 to mandate that enhanced use lease agreements require developers to certify the seismic safety of buildings or to have a plan for mitigating identified seismic deficiencies prior to renewal or execution of new facility use agreements with VA organizations.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
We recommended the Under Secretary for Health develop policies and procedures requiring VHA medical facilities to develop and test Continuity of Operations Plans, to include documenting the testing performed, in accordance with Federal Continuity Directive 1 requirements.
Combined Assessment Program Review of the Charles George VA Medical Center,Asheville, North Carolina
|
15-00621-23

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2015
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the Surgical Work Group meet monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility include most services in the review of electronic health record quality.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
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: 3/29/2016
We recommended that facility managers ensure negative air pressure systems on the surgical intensive care unit are functional and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure that locked mental health unit stationary and portable panic alarm testing includes documentation of VA Police response times.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the corrective actions until fully resolved.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for nursing employee users and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
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
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility revise the local policy to include that all designated non-anesthesia providers receive training in emergency airway management.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility complete a root cause analysis for the event to determine why this vulnerability existed and initiate appropriate system improvements.
Combined Assessment Program Review of the VA Pacific Islands Health Care System, Honolulu, Hawaii
|
15-00626-28

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that Environment of Care Committee meeting minutes consistently document tracking of identified deficiencies to closure and that monthly meetings consistently include community based outpatient clinic representation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that Infection Control Committee meeting minutes consistently reflect discussion of identified high-risk areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that facility managers ensure furnishings and equipment in patient care areas are in good repair and have upholstery that is easily cleaned.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure employees routinely inspect Center for Aging privacy and shower curtains and initiate actions to replace those with stains.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers ensure heavy-use public restrooms in the ambulatory care center have frequent inspections and receive cleaning as needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that facility managers initiate corrective actions to repair the ceiling leak in the ambulatory care center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that employees store clean and dirty items separately and promptly remove cardboard boxes from storage areas and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2016
We recommended that facility managers ensure negative air pressure systems are functional in all designated rooms and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that facility managers ensure all chairs in the acute psychiatry unit 3B2 dining/activity room are weighted.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility’s Emergency Operations Plan include all required Joint Commission elements.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility implement an adequate back-up plan for a Suicide Prevention Coordinator.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2016
We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and for identifying and tracking patients who are at high risk for suicide
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the facility implement a process to follow up on patients who miss MH appointments and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that clinicians include patients and/or their families in safety plan development and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that mental health providers ensure outpatients flagged as high risk for suicide have a suicide prevention safety plan completed within the first 72 hours of contact and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that mental health providers ensure outpatients flagged as high risk for suicide are evaluated at least four times within 30 days of flag placement if an outpatient or at least four times within 30 days of discharge from the inpatient psychiatric unit and that facility managers monitor compliance.
Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri
|
15-00600-33

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the privileges to do so.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers ensure emergency airway management privileges for licensed independent practitioners are reviewed, signed, and dated prior to granting the privileges.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the Cardiopulmonary Resuscitation Committee review all episodes of care where resuscitation was attempted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility ensure the recently established Safe Patient Handling Committee continues to meet and provide oversight of the safe patient handling program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers ensure all sharps containers are sealed tightly at the point of collection and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that facility managers ensure evacuation devices are immediately accessible in patient care areas and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that for all construction projects, the facility initiate Interim Life Safety Measures as required and post any needed alternative exit signage and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility revise the computed tomography policy to include a quality control program.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility revise the emergency airway management policy to include a plan to manage a difficult airway.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements 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 the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2016
We recommended that facility managers strengthen processes to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and in instances of occurrence, initiate root cause analyses.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that the facility ensure all home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order and that facility managers monitor compliance.
Healthcare Inspection – Alleged Program Inefficiencies and Delayed Care, Veterans Health Administration’s National Transplant Program
|
15-00187-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Under Secretary for Health review the extent of delays in responses to referrals for transplant evaluations; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely responses to referrals for liver transplant evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Under Secretary for Health review the extent of delays in initial patient evaluations for transplantation; assess the risk, if any, posed by those delays; and, take appropriate action to ensure timely initial patient evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2016
We recommended that, after reviewing the circumstances of delays in responses to referrals and initial patient evaluations for transplantation, the Under Secretary for Health take action to confirm that any patients who experienced delayed care that presented risks received appropriate care.
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