All Reports

Combined Assessment Program Review of the VA Maine Healthcare System, Augusta, Maine
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15-00605-544

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the Facility Director chair or co-chair the Performance Improvement Board.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that facility managers review privilege forms annually and document the review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassess observation criteria and utilization.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the Special Care Unit Committee review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2016
We recommended that the facility consistently include most services in the review of electronic health record quality.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2016
We recommended that the quality control policy for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, a complete review of scanned documents to ensure readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that facility managers ensure patient care areas are clean and damaged wall surfaces are repaired and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that facility managers ensure the walkway from the handicapped parking area to the main entrance is repaired.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2016
We recommended that employees promptly remove expired or undated medications from patient care areas and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2016
We recommended that the facility develop a written policy for safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the facility create/designate a committee to oversee consult management.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that employees consistently correctly post patients' advance directives status and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that facility managers ensure that special care unit nurses have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the facility revise the emergency airway management policy to include the availability of portable video laryngoscopes, the use of a device to confirm endotracheal tube placement in conjunction with auscultation, and a plan for managing the difficult airway.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2016
We recommended that facility managers ensure completion of initial assessments for emergency airway management competency prior to the clinicians providing coverage.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
Review of Patient-Centered Community Care (PC3) Health Record Coordination
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15-00574-501

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended the Under Secretary for Health implement a mechanism to ensure payments are not made to Patient-Centered Community Care contractors until all required clinical documentation is received.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended the Under Secretary for Health enforce Patient-Centered Community Care contract performance requirements to ensure that contractors return complete clinical documentation timely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2016
We recommended the Under Secretary for Health implement a mechanism to verify contractors¿ performance without relying on contractors¿ self-reported data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2016
We recommended the Under Secretary for Health complete a review of TriWest's performance and apply penalties if it is determined there is a lack of performance related to the timely return of clinical documentation.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2016
We recommended the Under Secretary for Health review the contract disincentives applied to HealthNet and determine if additional funds need to be recouped from the contractor and pursue collection if disincentives were under applied.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended the Under Secretary for Health ensure that Patient-Centered Community Care contractors annotate on all diagnostic imaging reports and non-imaging-related critical findings submitted to VA the name of the VA person contacted, and the date and time of the contact.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2016
We recommended the Under Secretary for Health implement procedures to verify whether Patient-Centered Community Care contractors and their network providers correctly and timely report critical findings to VA and impose financial penalties or other remedies when contractors fall below the contract performance threshold.
Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey
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15-00616-543

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management are granted privileges to perform the procedure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies and include corrective actions and tracking of actions to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure employees initiate corrective actions when sterile supply room temperature and/or humidity values are out of range and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that the facility repair or replace damaged paper towel dispensers in patient and public restrooms and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that the facility repair damaged patient equipment and furnishings or remove them from service and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that facility managers ensure crash cart logs contain the correct lock number and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that employees follow up with inpatients who would like to discuss creating, changing, and/or revoking advance directives to ensure the discussion takes place and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency 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: 5/9/2016
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have all required competency elements prior to being assigned coverage.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2016
We recommended that facility managers ensure video laryngoscopes are available in all designated locations at the Lyons campus and monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure that the Domiciliary Care for Homeless Veterans Program has signage alerting veterans and visitors of closed circuit television recording.
Review of VHA's Patient-Centered Community Care (PC3) Provider Network Adequacy
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15-00718-507

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended the Under Secretary for Health ensure the establishment of an adequate governance structure to oversee and improve Patient-Centered Community Care management and operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended the Under Secretary for Health ensure adequate implementation and performance monitoring plans are developed for future high-dollar, complex health care initiatives.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2016
We recommended the Under Secretary for Health assess where Patient-Centered Community Care provider networks are inadequate and develop action plans to improve provider networks that are unable to provide health care services at the specific geographic locations identified.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2016
We recommended the Under Secretary for Health ensure the Patient-Centered Community Care Quality Assurance Surveillance Plan is revised to address the monitoring and measurement of network adequacy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended the Under Secretary for Health require the input of National Provider Identifier information for rendering providers in the Fee Basis Claims System to ensure adequate data are available for program evaluation and planning.
Healthcare Inspection – Quality of Care Concerns in a Diagnostic Evaluation, Jesse Brown VA Medical Center, Chicago, Illinois
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14-02952-498

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director evaluate the scheduling process for vascular consultations and diagnostic tests and take action if factors potentially impacting quality of care are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director evaluate the practice of vascular laboratory technicians interpreting the urgency of providers’ consult requests and whether providers are notified when consult requests are not scheduled within the providers’ timeframe and take action if needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director develop a policy defining who is responsible for provider and patient notification of consults ordered through the Emergency Department or Urgent Care Clinic that are not completed timely according to Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that providers perform comprehensive pain assessments according to Veterans Health Administration policy and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director conduct an internal evaluation of the case discussed in this report.
Review of Allegations of Inappropriately Completed Consults and Inappropriate Bonuses at the St. Louis VA Health Care System
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14-03434-530

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended the Director of the St. Louis VA Health Care System ensure scheduling staff receive appropriate training and guidance on proper consult management.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended the Director of the St. Louis VA Health Care System perform a follow-up analysis and regular oversight of completed consults to ensure consults are not designated as “Complete” before the provider sees the patient.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of William S. Middleton Memorial Veterans Hospital, Madison, WI
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15-00165-529

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2016
We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Baraboo VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2016
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2016
We recommended that the Acting Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2016
We recommended that the Acting Facility Director ensures that the facility's written policy for the communication of laboratory results included all required elements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2016
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 Alaska VA Healthcare System, Anchorage, Alaska
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15-00166-531

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fairbanks CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that staff store clean supplies separate from infectious materials at the Fairbanks CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
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: 5/10/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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: 5/10/2016
We recommended that providers 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: 2/10/2016
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
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: 5/10/2016
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: 2/10/2016
We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Administrative Investigation: Inappropriate Use of Position and Misuse of Relocation Program and Incentives in VBA
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15-02997-526

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary review the Department's request and approval process for the Appraised Value Option program and make improvements as deemed appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/22/2017
We recommended the Deputy Secretary review the Department’s request and approval process for temporary quarters subsistence expense allowance and make improvements as deemed appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary consult with the Office of General Counsel to determine whether Ms. Rubens should be issued a bill of collection for $123.50 to recoup the improper reimbursements paid to her for alcoholic beverages and unauthorized meals and tips.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/9/2017
We recommended the Deputy Secretary strengthen the approval process to include requiring an independent review of the Department’s Permanent Change of Station program to ensure moves and expenses are appropriate and justified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/27/2017
We recommended the Deputy Secretary require the Veterans Benefits Administration to establish policies and procedures to standardize its practices regarding annual salary increases when reassigning Senior Executives’ positions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/17/2016
We recommended the Deputy Secretary consult with the Office of General Counsel to determine whether bills of collection should be issued to recover unjustified relocation incentives paid by the Veterans Benefits Administration for Senior Executive reassignments.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/27/2017
We recommended the Deputy Secretary consult with the Office of General Counsel to determine what actions may be taken to hold the appropriate Senior Officials accountable for processing and approving payments of unjustified relocation incentive payments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Rubens.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/17/2016
We recommended that the Deputy Secretary consult with the Office of General Counsel to determine whether a bill of collection should be issued to Ms. Rubens to recoup the $274,019 paid for expenses related to her relocation.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Graves.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 3/17/2016
We recommended that the Deputy Secretary consult with the Office of General Counsel to determine whether a bill of collection should be issued to Ms. Graves to recoup the $129,468 paid for expenses related to her relocation.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 5/20/2016
We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Hickey, Mr. Pummill, and Ms. McCoy.
Review of Alleged Data Sharing Violations at VA's Palo Alto Health Care System
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14-04945-413

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/14/2016
We recommended the VA Assistant Secretary for Information and Technology take action to ensure the Palo Alto Health Care System Information Security Officers conduct a risk assessment of Kyron software to identify potential risks, vulnerabilities, and threats to VA systems and sensitive information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/14/2016
We recommended the VA Assistant Secretary for Information and Technology implement appropriate controls to ensure that unauthorized software is not procured or installed on VA networks without a formal risk assessment and approval to operate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/14/2016
We recommended the Palo Alto Health Care System Management, in conjunction with VA’s Assistant Secretary for Information and Technology, ensure Kyron personnel receive commensurate background investigations and obtain formal authorization to operate Kyron software on VA networks.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/14/2016
We recommended the Palo Alto Health Care System Management, in conjunction with VA’s Assistant Secretary for Information and Technology, require Kyron personnel to complete security awareness training and sign the Contractor Rules of Behavior to ensure full awareness of VA information security requirements when accessing VA systems and networks.
Combined Assessment Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky
|
15-00619-515

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that facility managers ensure that licensed 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: 2/4/2016
We recommended that the Surgical Work Group meet monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2016
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that facility managers ensure negative air pressure systems in the medicine primary care clinic are functional and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that facility managers ensure locked mental health unit stationary panic alarm testing includes documentation of VA Police response time.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2015
We recommended that equipment on the locked mental health unit is secured and heavy enough to prevent it from being picked up, thrown, moved, or overturned.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2016
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: 2/4/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required subject matter content elements and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility revise the local policy for out of operating room emergency airway management to include successful demonstration of all required procedural skills on airway simulators for providers seeking renewal of privileges.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2016
We recommended that the facility document the review of provider-specific emergency airway management data in Cardiopulmonary Review Committee meeting minutes.
Inspection of VA Regional Office Honolulu, Hawaii
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15-01996-503

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Honolulu VA Regional Office Director provide training on traumatic brain injury claims and assess the effectiveness of that training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Honolulu VA Regional Office Director ensure frequent refresher training for processing higher levels of special monthly compensation and ancillary benefits claims and monitor the effectiveness of this training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Honolulu VA Regional Office Director strengthen the review process for higher levels of special monthly compensation and ancillary benefits claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Honolulu VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Review of Land Purchase for the Replacement Hospital in Louisville, Kentucky
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14-02666-456

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/14/2016
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction establish formal VA policy and procedures regarding review appraisals and ensure its dissemination.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/14/2016
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction establish an internal review board to enforce compliance with Federal laws and VA policies governing VA land purchases.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/14/2016
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction determine the appropriate administrative actions to take for noncompliance with regulations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,057,447.00
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
|
15-00153-508

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: 2/8/2016
We recommended that the information technology server closet at the Belmont County VA Clinic is maintained according to information technology safety and security standards.
No. 2
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. 3
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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching 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: 2/8/2016
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Inspection of VA Regional Office Sioux Falls, South Dakota
|
15-01860-502

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: 9/15/2015
We recommended the Sioux Falls VA Regional Office Director conduct a review of the 22 temporary 100 percent disability evaluations remaining from their inspection universe as of February 11, 2015, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended the Sioux Falls VA Regional Office Director implement a plan to improve the effectiveness of the second-signature review process for special monthly compensation and ancillary benefits claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended the Sioux Falls VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Robley Rex VA Medical Center, Louisville, Kentucky
|
15-00170-517

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that patient-identifiable information on laboratory specimens is secured during transport from the Newburg VA Clinic to the Robley Rex VA Medical Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that staff protect and secure patient-identifiable information at the Newburg VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinic Registered Nurse Care Managers receive motivational interviewing 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: 2/8/2016
We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by VHA and local policy and that compliance is monitored.
Follow-up Review of VA’s Veterans Benefits Management System
|
13-00690-455

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 9/14/2015
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, implement improved cost controls and stabilize Veterans Benefits Management System functionality requirements for the remainder of planned system development to restrict further cost increases.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 5/13/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, perform a formal budget versus cost analysis to identify actual costs expended in support of the Veterans Benefits Management System development effort.
No. 3
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 9/14/2015
We recommended the Executive in Charge for the Office of Information and Technology perform market analyses on all future Space and Naval Warfare Systems Command Atlantic task orders to determine whether the continued use of the interagency agreements is in the best interest of the Department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 2/21/2018
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, establish a clear strategy and plan to decommission legacy systems, eliminate redundant systems operations, and reduce system maintenance costs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 8/9/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, fully develop and implement Veterans Benefits Management System electronic workflow and workload brokering functionality to facilitate more efficient claims processing.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, provide adequate training with each Veterans Benefits Management System release to ensure VA Regional Office users fully benefit from the enhanced functionality provided.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology implement an improved Veterans Benefits Management System network infrastructure to mitigate single points of failure and reduce the network performance issues across the enterprise.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, develop sufficient Veterans Benefits Management System performance metrics to demonstrate the system is improving VA¿s ability to efficiently process claims as compared to legacy practices.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/13/2016
We recommended the Executive in Charge for the Office of Information and Technology minimize the use of manual requirements tracking processes and maximize the use of automated application lifecycle management tools to manage requirements traceability in accordance with industry best practices.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 27,000,000.00
Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina
|
15-00615-513

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that the Surgical Work Group meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that the facility designate a clinical subject matter expert to oversee emergency airway management.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2016
We recommended that the facility ensure clinicians designated for out of operating room airway management coverage have current scopes of practice and documentation of all required elements and that facility managers monitor compliance.
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