All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Battle Creek VA Medical Center, Battle Creek, Michigan
|
15-00155-16

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that staff protect and secure specimens and patient-identifiable information at the Muskegon VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Muskegon VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that staff position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas at the Muskegon VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2016
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA New Jersey Health Care System, East Orange, New Jersey
|
15-00163-01

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that managers ensure a safe, clean, and well maintained environment of care at the Morristown VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Morristown VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that all employees at the Morristown VA Clinic receive the required training on hazardous materials.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that managers ensure that all safety inspections on medical equipment are performed as required by facility policy at the Morristown VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Morristown VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that staff are trained to properly disinfect non-critical medical equipment as required at the Morristown VA Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Morristown VA Clinic staff protect patient-identifiable information on laboratory specimens during transport.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that the information technology server closet at the Morristown VA Clinic 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: 6/20/2016
We recommended that managers ensure that all staff at the Morristown VA Clinic are trained to safely evacuate using all exit routes from the building.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2016
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Marion VA Medical Center, Marion, Illinois
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15-00177-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2016
We recommended that managers ensure that safety data sheets are current at the Paducah VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2016
We recommended that managers ensure staff can access the electronic version of safety data sheets at the Paducah VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2016
We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Paducah VA Clinic in accordance with Joint Commission standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Paducah VA Clinic to the parent facility.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing 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: 5/16/2016
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
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: 3/28/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
|
15-00622-06

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Cardiopulmonary Resuscitation Subcommittee review each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Operating Room Management Council meet monthly, include the Chief of Staff and Surgical Quality Nurse as members, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Operating Room Management Council review all surgical deaths with identified problems or opportunities for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the Infection Prevention and Control Sub-Committee document follow-up on actions implemented to address identified problems.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that facility managersensure designated employees receive evacuation device training and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for users and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that radiologists document the radiation dose in the Computerized Patient Record System and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that employees consistently use appropriate note titles to document advance directive screening and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that employees consistently 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)
Closure Date: 10/19/2015
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/22/2016
We recommended that the facility consistently perform continuing stay reviews on at least 75 percent of patients in acute beds.
Healthcare Inspection – Access to Urology Service, Phoenix VA Health Care System, Phoenix, AZ
|
14-00875-03

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2016
We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that resources are in place to deliver timely urological care to patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that non-VA care providers’ clinical documentation is available in the electronic health records in a timely manner for Phoenix VA Health Care System providers to review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the Phoenix VA Health Care System Interim Facility Director ensure that the cases identified in this report are reviewed, and for patients who suffered adverse outcomes and poor quality of care, confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
Healthcare Inspection – Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon
|
15-00506-535

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the Acting Under Secretary for Health perform a quality review of the Chief of Surgery's colonoscopies performed in the prior Veterans Health Administration facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the Acting Under Secretary for Health revise the Veterans Health Administration Colorectal Cancer Screening directive to include standardized documentation of quality indicators based on professional society guidelines and published literature (including but not limited to photodocumentation of anatomical landmarks establishing cecal intubation and documentation of cecal withdrawal times).
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2017
We recommended that the Acting Under Secretary for Health consider adding photodocumentation of cecal intubation and cecal withdrawal time to the standardized criteria for quality colonoscopy for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the System Director ensure patient notification of diagnostic test results within the required timeframe, particularly for critical results, and that clinicians document notification.
Review of Alleged Improper Pay at VHA's Hudson Valley Health Care System
|
15-02053-537

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System conducts a review of all Federal Wage Service employees’ official duty stations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System takes action to correct any inappropriate Federal Wage Service employees’ official duty stations and wage rates.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System provides training to all management and Human Resources personnel on how to correctly determine an employee’s official duty station.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System develops procedures to monitor the accuracy of Federal Wage Service employees’ official duty station.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2017
We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review and consult appropriate VA offices, including the Office of General Counsel, to determine whether administrative action is appropriate for those officials in the Engineering, Environmental Management, and Human Resources Services who did not adequately review or correct employees’ official duty stations in response to the 2014 Office of Human Resources and Administration’s request for verification of all employees’ official duty stations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,555,318.00
Healthcare Inspection – Alleged Suicides and Inappropriate Changes to Mental Health Treatment Program, Coatesville VA Medical Center, Coatesville, Pennsylvania
|
13-04038-521

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that the Facility Director coordinate with Veterans Health Administration leadership regarding the establishment of a Psychosocial Rehabilitation and Recovery Center.
Review of VBA's Alleged Mismanagement of Unemployability Benefits at VARO Seattle, Washington
|
15-02745-522

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended that the Pacific District Director convene an administrative investigation board to determine why VA Regional Office management was unaware that Intake Processing Center staff had stored unprocessed mail for several months without action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended the Pacific District Director convene an administrative investigation board to determine why staff responsible for managing mail did not seek assistance for processing employment questionnaires for several months.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2016
We recommended the VA Regional Office Director conduct refresher training for staff responsible for processing mail with emphasis on processing employment questionnaires.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2015
We recommended the Under Secretary for Benefits implement a plan that requires audit trails coexist with corrective action plans when areas of mismanagement or data manipulation are identified at VA Regional Offices.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pacific Islands Health Care System, Honolulu, Hawaii
|
15-00180-538

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that managers maintain a clean and functioning environment of care at the American Samoa VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the American Samoa VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that managers ensure that safety data sheets are readily available to staff at the American Samoa VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2017
We recommended that hand hygiene compliance is monitored at the American Samoa VA Clinic and reported to the Infection Control Committee.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious) waste at the American Samoa VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2016
We recommended that written procedures are available and staff are trained to properly disinfect non-critical medical equipment as required at the American Samoa VA Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that the information technology server closet at the American Samoa VA Clinic is maintained according to information technology safety and security standards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that panic alarms are installed and tested, and testing is documented in all high-risk areas at the American Samoa VA Clinic.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that the staff at the American Samoa VA Clinic receive regular information/updates on their responsibilities in emergency response operations.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Review of Alleged Inappropriate Referrals at VHA’s Southern Nevada Healthcare System to a Non-VA Medical Provider
|
15-01590-523

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended the Under Secretary for Health ensure that TriWest Healthcare Alliance Corporation meets the terms of the Patient-Centered Community Care contract by referring radiation oncology patients to only American College of Radiology-accredited network practices/facilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended the Under Secretary for Health determine whether the Patient-Centered Community Care contract with TriWest Healthcare Alliance Corporation needs to be amended to allow referrals to other than American College of Radiology-accredited network practices/facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended the Under Secretary for Health require the review of medical results for the 15 patients referred to practices/facilities not accredited by the American College of Radiology or American College of Radiation Oncology to ensure they received treatment that met Veterans Health Administration standards of care.
Combined Assessment Program Review of the Manchester VA Medical Center, Manchester, New Hampshire
|
15-00620-548

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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 prior to the final level assignment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers review privilege forms annually and document the review.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Code Committee review each code episode.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Safe Patient Handling Committee meet monthly and provide oversight of the safe patient handling program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include the quality of the source document, 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, and a complete review of scanned documents to ensure readability and retrievability.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility assign the Suicide Prevention Coordinator full time to suicide prevention activities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
|
15-00176-541

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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 staff protect patient-identifiable information on laboratory specimens during transport from the El Dorado VA Clinic to the parent facility or contracted processing facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2015
We recommended that the information technology server closet at the El Dorado VA Clinic is maintained according to information technology safety and security standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2016
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: 1/21/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2016
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: 9/12/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Inspection of VA Regional Office Los Angeles, California
|
15-01110-493

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/10/2016
We recommended the Los Angeles VA Regional Office Director conduct a review of the 522 temporary 100 percent disability evaluations remaining from our inspection universe as of December 2014, and take appropriate actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommended the Los Angeles VA Regional Office Director implement a plan to ensure oversight and prioritization of temporary 100 percent disability evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommended the Los Angeles VA Regional Office Director implement a plan to monitor the effectiveness of training on traumatic brain injury claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommended the Los Angeles VA Regional Office Director implement a plan to ensure staff comply with Veterans Benefits Administration's second-signature requirements for traumatic brain injury claims, and the local procedures for processing traumatic brain injury claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommended the Los Angeles VA Regional Office Director provide training on higher levels of special monthly compensation for all staff members responsible for evaluating or providing second-signature reviews for these cases.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/28/2016
We recommended the Los Angeles VA Regional Office Director implement a plan to ensure oversight and prioritization of benefit reduction cases.
Combined Assessment Program Review of the VA Maine Healthcare System, Augusta, Maine
|
15-00605-544

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: 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

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: 8/23/2016
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.
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