All Reports

Combined Assessment Program Summary Report – Evaluation of Safe Medication Storage Practices in Veterans Health Administration Facilities
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16-00693-269

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities’ policies include automated dispensing machine user training and competency assessment requirements and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees perform and document monthly inspections of all medication storage areas and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when employees identify deficiencies during medication storage area inspections, they document corrective actions and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities have oral syringes available for medication administration and clearly label and store them separately from parenteral syringes and that facility managers monitor compliance.
Review of Community Based Outpatient Clinic and Other Outpatient Clinics of Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
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16-00017-245

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that managers monitor hand hygiene compliance at the Selma VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2016
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Review of VBA’s Alleged Inappropriate Prioritization of Appeals at VARO Roanoke, VA
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15-02384-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/19/2016
We recommended that the Roanoke VA Regional Office Director ensure that leadership and appeals staff follow the workload management plan to prioritize work based on the appeals pending the longest.
Combined Assessment Program Review of the Carl Vinson VA Medical Center, Dublin, Georgia
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16-00115-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that facility managers ensure Peer Review Committee monthly meetings are documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that Environment of Care Committee meeting minutes reflect sufficient discussion of environment of care rounds deficiencies, corrective actions taken to address the deficiencies, and tracking of actions to closure for the facility and the community based outpatient clinics.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that facility managers ensure operating room housekeepers complete initial training on cleaning and disinfection procedures.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2016
We recommended that the facility develop a policy that addresses temporary bed locations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently identify and document deficiencies concerning resident privacy, submit work orders for items needing repair, and document corrective actions taken for identified deficiencies and that program managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband, 2-hour rounds of all public spaces, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that the unit 10-B and unit 8-B main points of entry have keyless entry systems.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/19/2016
We recommended that facility managers ensure that the closed circuit television system on unit 8-B have recording capabilities and that unit 10-B have signage alerting veterans and visitors of closed circuit television recording.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Charlie Norwood VA Medical Center, Augusta, Georgia
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16-00012-251

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2016
We recommended that employees at the Statesboro 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: 11/17/2016
We recommended that managers ensure that Statesboro VA Clinic staff participate in emergency management training and exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that the clinic manager ensures that Statesboro VA Clinic employees receive the required hazardous communications training.
No. 4
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
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: 8/25/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Fargo VA Health Care System, Fargo, North Dakota
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16-00023-252

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians document assessments and treatment plans for Home Telehealth patients.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure 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)
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe required by VHA.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Cheyenne VA Medical Center, Cheyenne, Wyoming
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16-00019-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2017
We recommended that the clinic manager reviews the Greeley VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Kansas City VA Medical Center, Kansas City, Missouri
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16-00013-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2016
We recommended that the Facility Director ensures that signs identify the location of fire extinguishers that are in large rooms or are obscured from view at the Cameron VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the clinic manager reviews the Cameron VA Clinic's hazardous materials inventory twice within a 12-month period.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that the Cameron VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that clinic staff protect patient-identifiable information on laboratory specimens during transport.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2016
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: 11/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Claims-Related Documents Pending Destruction at VA Regional Offices
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15-04652-146

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/14/2019
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to ensure documents printed from Veterans Benefits Management System are clearly identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to include detailed, standardized procedures for the collection and review of material by records management staff at VA Regional Offices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure all claims-related documents receive the mandated levels of review to comply with Veterans Benefits Administration’s policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/15/2017
We recommended the Acting Under Secretary for Benefits implement a plan that requires supervisors to conduct periodic reviews of employees’ red boxes and track all shredding policy violations they identify.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2018
We recommended the Acting Under Secretary for Benefits implement a plan to ensure records management staff comply with Veterans Benefits Administration’s policy to track all shredding violations they identify.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits implement a plan to ensure management and staff receive refresher training on the proper handling of both claims-related and non-claims-related documents.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2017
We recommended the Acting Under Secretary for Benefits develop specific procedures regarding the maintenance and disposition of congressional correspondence.
Review of Alleged Shredding of Claims-Related Evidence at VARO Los Angeles, CA
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15-04652-266

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2016
We recommended the VA Regional Office Director implement a plan to ensure the Los Angeles VA Regional Office staff comply with the Veterans Benefits Administration’s policy for handling, processing, and protection of claims-related documents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2016
We recommended the VA Regional Office Director assess the effectiveness of the training provided to the Los Angeles VA Regional Office staff on Veterans Benefits Administration’s policy for managing veterans’ and other governmental records.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/24/2016
We recommended the VA Regional Office Director provide documentation to VA OIG that proper action has been taken to process the eight cases that had the potential to affect veterans’ benefits.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma
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16-00011-259

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that employees at the Hartshorne 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: 11/30/2016
We recommended that managers ensure that Hartshorne VA Clinic staff participate in emergency management training and exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility Director ensures that a policy/procedure is in place for the identification of individuals entering the Hartshorne VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility Director ensures that a Workplace Behavioral Risk Assessment is in place for the Hartshorne VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2016
We recommended that the Facility Director ensures examination room doors are equipped with electronic or manual locks at the Hartshorne VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2016
We recommended that the Hartshorne VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2016
We recommended that the Hartshorne VA Clinic manager provides feminine hygiene disposal bins in women's public restrooms.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2016
We recommended that the Hartshorne VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2016
We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2017
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: 2/14/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2017
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2016
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Healthcare Inspection – Restraint Use, Failure To Provide Care, and Communication Concerns, Bay Pines VA Healthcare System, Bay Pines, Florida
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15-01432-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that Emergency Department, Computed Tomography Department, Patient Advocate, and 5B inpatient medical unit staff receive patient-centered care training and/or refresher training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director conduct a review of the patient advocates’ actions as described in this report and take action as appropriate, including providing guidance regarding the processing of patient/family concerns.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that physician orders are entered into the electronic health record as required when restraints are used.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that physician discharge notes contain all required elements and documentation adequately reflects the patient’s care and communication with family.
Combined Assessment Program Review of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma
|
16-00102-253

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2017
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure ventilation system outlets are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor temperature in the compounding buffer areas and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees perform and document monthly cleaning of ceilings, walls, lights, and storage shelving in all compounding areas and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that physicians consistently document discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide discharge instructions to patients and/or caregivers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2017
We recommended that radiologists document the radiation dose in the Computerized Patient Record System 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 annual radiation safety training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Combined Assessment Program Summary Report - Evaluation of Emergency Airway Management in Veterans Health Administration Facilities
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16-00969-257

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure facilities’ policies include plans for managing difficult airways.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers provide all required initial training for designated employees who will perform airway management and ensure initial competency assessment includes all required testing and demonstration and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers include all required elements in airway management competency reassessments and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure competent clinicians provide emergency airway management during all hours of patient care unless the facility is exempt and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers conduct root cause analyses when clinicians without demonstrated airway management competency perform emergency intubations and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure scopes of practice for non-licensed independent practitioners who perform airway management include a statement related to airway management and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility Chiefs of Staff ensure clinicians complete required training and experience within a short timeframe after recommending airway management privileges and that facility managers monitor compliance.
Inspection of VA Regional Office Montgomery, AL
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15-04987-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2016
We recommended the Montgomery VA Regional Office Director develop and implement a plan to ensure staff take timely actions on reminder notifications to request medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/11/2016
We recommended the Montgomery VA Regional Office Director conduct a review of the 15 temporary 100 percent disability evaluations remaining from our inspection universe as of August 11, 2015, and take appropriate actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2016
We recommended the Acting Under Secretary for Benefits implement a time frame in which staff are required to schedule medical reexaminations to ensure accurate benefits payments to veterans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2016
We recommended the Montgomery VA Regional Office Director implement a plan to prioritize actions related to benefits reductions to minimize improper payments to veterans.
Combined Assessment Program Review of the Cheyenne VA Medical Center, Cheyenne, Wyoming
|
16-00110-246

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
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: 8/11/2016
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: 11/22/2016
We recommended that facility managers ensure medical waste/biohazard containers are properly covered and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2016
We recommended that the facility develop a policy that addresses temporary bed locations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2016
We recommended that the facility revise the Radiation Safety Program policy to include a computed tomography quality control program with annual monitoring by a medical physicist and image quality monitoring, protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer, a process for managing/reviewing protocols and procedures to follow when revising protocols, and radiologist review of appropriateness of orders and specification of protocol prior to scans.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2016
We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and tracking patients who are at high risk for suicide.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2017
We recommended that the facility implement a process to follow up on high-risk patients who missed mental health appointments and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2016
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2017
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2016
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
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16-00107-256

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No. 1
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. 2
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 monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove outdated commercial supplies from patient care areas and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure operating rooms are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace damaged furniture in the operating rooms.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the competency assessment policy for employees who prepare compounded sterile products to include the required intervals for gloved fingertip sampling.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the compounded sterile products safety policy to include verification of all finished compounded sterile products by a pharmacist.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees perform and document cleaning of storage shelving and bins in all compounding areas and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide discharge instructions to patients and/or caregivers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a plan for transition to the allowed note titles.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees use the required advance directive note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the mammography services policy includes all required elements.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Controlled Substances Coordinator ensure all required non-pharmacy areas with controlled substances are inspected and monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility strengthen processes to ensure weekly inventories of automated dispensing machines are consistently conducted and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
|
16-00016-241

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that contracted Environmental Management Service employees at the Fredericksburg 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: 12/12/2016
We recommended that the clinic manager ensures that Fredericksburg VA Clinic contracted Environmental Management Service employees receive the required hazardous communications training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the clinic manager reviews the Fredericksburg VA Clinic's hazardous materials inventory twice within a 12-month period.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2016
We recommended that the Fredericksburg VA Clinic manager provides feminine hygiene products and disposal bins in women's public restrooms.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that clinicians document verbal informed consent for Home Telehealth services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2016
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: 2/14/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2016
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri
|
15-04695-231

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility replace missing/stained ceiling tiles in patient care areas.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that facility managers ensure all patient care areas have secure storage for protected health information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended that the facility assess the possible subfloor penetration and replace missing and broken floor tiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that facility managers ensure employees perform and document daily floor and monthly storage shelving cleaning in all compounding areas and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Review of Alleged Noncompliance With Section 508 of the Rehabilitation Act on MyCareer@VA Web Site
|
15-02781-153

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration correct all Section 508 compliance issues with the MyCareer@VA Web site and seek certification of Section 508 compliance from the appropriate component within VA Section 508.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration develop and implement a process to ensure their products conform with Section 508 requirements prior to their deployment, which includes defining what support is required to document a product¿s compliance with Section 508 requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2016
We recommended the Assistant Secretary for Human Resources and Administration provide and require training for all individuals involved in developing and maintaining products to ensure they are aware of the requirements and expectations for conformance with Section 508 requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/22/2019
We recommended the Assistant Secretary for Information and Technology strengthen policy to ensure Electronic and Information Technology products are compliant with Section 508 prior to their deployment, which includes providing an expectation of when to establish compliance, how to document compliance, and what specifically constitutes compliance with Section 508.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 34,011.00
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