Date Issued
|
Report Number
14-02890-262
All Reports
Date Issued
|
Report Number
16-00104-230
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes gloved fingertip sampling.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that facility managers ensure all compounded sterile product labels contain the preparer and checker initials and the beyond use date.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that physicians consistently document discharge progress notes or instructions that include all required elements and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility manager’s monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/13/2016
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/13/2017
We recommended that clinicians include documentation of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Date Issued
|
Report Number
15-01227-129
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address if and when a Conference Package may be used to summarize the budgets for multiple events and how to present the budget for each event to ensure adequate line item detail for each event.
No. 2
to Office of Management (OM)
Closure Date: 1/13/2017
We recommended the Interim Assistant Secretary for Management update existing guidance to address how to present line item detail of expenditures in the Final Conference Reports if the approved Conference Package was for multiple events to ensure traceability to source documents.
No. 3
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management establish review procedures that ensure Conference Packages and Final Conference Reports comply with law and VA policy and report the results to the Deputy Secretary or VA Chief of Staff.
No. 4
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to provide adequate accountability to ensure that VA organizations comply with conference policies.
No. 5
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Conference Certifying Official as the reviewer of the Conference Package instead of the Responsible Conference Executive.
No. 6
to Office of Management (OM)
Closure Date: 1/31/2017
We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Corporate Travel Reporting Office review of Conference Packages with a budget of $100,000 or more before submitting the package for Deputy Secretary or Secretary approval.
Date Issued
|
Report Number
14-02890-258
Date Issued
|
Report Number
14-02890-248
Date Issued
|
Report Number
14-02890-237
Date Issued
|
Report Number
14-02890-250
Date Issued
|
Report Number
15-01651-209
Date Issued
|
Report Number
14-02890-232
Date Issued
|
Report Number
14-02890-243
Date Issued
|
Report Number
14-03048-226
Date Issued
|
Report Number
14-04897-221
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/31/2016
We recommended that the System Director ensure that primary care providers follow established guidelines for referral of patients with chronic pain as required by VA policy.
Date Issued
|
Report Number
14-02890-236
Date Issued
|
Report Number
14-02890-224
Date Issued
|
Report Number
14-02890-227
Date Issued
|
Report Number
14-02890-247
Date Issued
|
Report Number
16-00106-211
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the availability of personal protective equipment masks in all patient care areas and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
We recommended that employees secure medication carts when not in use, remove expired medications from patient care areas, and date multi-dose vials when opened and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
We recommended that a medical physicist complete and document inspections of computed tomography scanners following repair or modifications affecting dose or image quality and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/7/2017
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that treatment teams follow up with patients at least four times during the first 30 days after discharge and that facility managers monitor compliance.
Date Issued
|
Report Number
15-01283-220
Date Issued
|
Report Number
14-02890-217
Date Issued
|
Report Number
14-02890-192