All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Iowa City VA Health Care System, Iowa City, Iowa
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15-00144-426

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
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: 9/6/2016
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: 3/9/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results include all required elements
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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15-00598-446

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2015
We recommended that the Medical Emergency Committee review each code episode.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Accident Review Board Committee share patient handling injury data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2015
We recommended that the quality control policy/process 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, and a complete review of scanned documents to ensure readability and retrievability.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the facility clean and/or repair soiled and/or damaged wheelchairs in patient care areas or remove them from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2016
We recommended that the Controlled Substances Coordinator provide quarterly trend reports to the Facility Director.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that controlled substances inspectors consistently inspect all required non-pharmacy areas with controlled substances and that the Controlled Substances Coordinator monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that facility managers ensure the Controlled Substances Coordinator sufficiently rotates controlled substances inspectors in inspection assignments and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that controlled substances inspectors complete inspections on the same day initiated and that the Controlled Substances Coordinator monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that the Facility Director ensure that the controlled substances inspection program has adequate oversight and complies with Veterans Health Administration policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/6/2016
We recommended that Domiciliary Care for Homeless Veterans Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas
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15-00596-429

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly.
No. 3
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, and a complete review of scanned documents to ensure readability and retrievability.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently document actions when data analyses indicated problems or opportunities for improvement and evaluate them for effectiveness in the Quality, Safety, and Value; Critical Care; Medical Records; and Infection Prevention and Control Committees and in the Environment of Care Council.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees offer patients the opportunity to review, revise, or rescind previously completed advance directives and document the discussions and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that respiratory therapy employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include an alternative for new employees, transfers from other VA medical centers, consultants or without compensation clinicians, and the availability of portable video laryngoscopes for use by clinicians for emergency airway management.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa
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15-00602-425

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
We recommended that pharmacy personnel conduct and document monthly medication storage area inspections and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2016
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: 2/9/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Healthcare Inspection – Quality of Care Issues, Sheridan VA Healthcare System, Sheridan, Wyoming
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14-00903-422

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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 ensure that staff comply with Veterans Health Administration and facility policies and practices related to the management of dysphagia, including assessment and documentation of a patient's response to the provided care recommendations and aspiration risk precautions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2016
We recommended that the Facility Director implement applicable recommendation(s) from previous event-related reviews, if any.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that the Facility Director review local privileging processes and ensures compliance with local policy and Veterans Health Administration Handbook 1100.19.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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15-00138-392

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that employees at the Haverhill CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Haverhill CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that the information technology server closet at the Haverhill CBOC is maintained according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that testing of the panic alarm system is conducted at the Haverhill CBOC.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2015
We recommended that Clinic Registered Nurse Care Managers and clinical associates 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: 4/28/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio
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15-00595-417

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, that the committee document the screening reviews, and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility include Social Work Service, Chaplain Service, and the Rehabilitation Medicine and Service Care Line in the review of electronic health record quality.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that facility managers ensure that patient care areas are clean and in good repair and that areas under sinks are not used for storage and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that the recently implemented Consult Management Committee continue to meet regularly to review consult data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and includes all required elements and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that facility managers ensure the Domiciliary and Psychosocial Residential Rehabilitation Treatment Programs are clean and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that the Domiciliary Residential Rehabilitation Treatment Program have a Class K fire extinguisher available in the kitchen used by residents.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that the facility correct the deficiencies identified during monthly Domiciliary Residential Rehabilitation Treatment Program self-inspections and that documentation reflects correction.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2016
We recommended that Domiciliary Residential Rehabilitation Treatment Program managers ensure residents secure medications in their rooms and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2016
We recommended that clinicians ensure that the safety plans for all patients assessed to be at high risk for suicide specifically address suicidality and that facility managers monitor compliance.
Healthcare Inspection – Vascular Surgery Resident Supervision, VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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14-04037-404

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the System Director ensure the timeframe for supervisor co-signature of inpatient resident progress notes is defined and documented.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the System Director ensure that attending surgeons cosign resident progress notes timely.
Healthcare Inspection – Alleged Poor Quality of Care and Refusal to Pay for Lung Transplantation, Iowa City VA Health Care System, Iowa City, Iowa
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15-01968-424

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2016
We recommended that the Interim Under Secretary for Health review how the Veterans Health Administration compensates non-VA facilities for lung transplantation to ensure that reimbursement is appropriate for the services performed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended that the System Director conduct a focused professional practice evaluation of the care provided by attending physicians at the facility during the patient’s fall 2014 hospitalization.
Healthcare Inspection – Alleged Dental Service Scheduling and Other Administrative Issues, VA Palo Alto Health Care System, Palo Alto, CA
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14-04755-428

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2016
We recommended that the Veterans Integrated Service Network Director review the dental program after corrective actions have been implemented to ensure that dental care at the system is timely and of high quality.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2016
We recommended that the System Director monitor the dental clinic to ensure that patients receive appropriate access to care, as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that the System Director implement recommendations as described in the 2011 Veterans Health Administration Office of Dentistry Workforce Study regarding staffing in dental clinics.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that the System Director ensure timely delivery of prosthetic devices and documentation of each step in the process and monitor compliance.
Healthcare Inspection – Alleged Consult Processing Delay Resulting in Patient Death, VA Eastern Colorado Health Care System, Denver, Colorado
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14-04049-379

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the NVCC consult process is clearly defined, the facility has appropriate processes in place to identify and address potential delays, and that compliance is monitored.
Healthcare Inspection – Alleged Short-Stay Rehabilitation Unit Concerns, Tuscaloosa VA Medical Center, Tuscaloosa, Alabama
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15-01445-400

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2016
We recommended that the Facility Director ensure that the assessments for patients screened for admission by the facility physiatrist consultant are documented in the electronic health records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that the Facility Director ensure Valor Center screening and admission policies are consistent with Valor Center practices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2016
We recommended that the Facility Director ensure that all relevant staff are notified of planned Valor Center admissions to allow staff sufficient time to make appropriate plans for required care and services.
Healthcare Inspection – Scheduling, Staffing, and Quality of Care Concerns at the Alaska VA Healthcare System, Anchorage, AK
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14-04077-405

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement an action plan based on ongoing monitoring of access performance measures that includes recruitment and retention, and ensure continued provision of primary care by a permanent provider at the Mat-Su VA Community Based Outpatient Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement contingency plans for ensuring patients receive continuity of and access to appropriate primary care during periods of inadequate resources, extended staff absences, staff turnover, understaffing, and nature-related events, as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement the requirements of Veterans Health Administration Handbook 1101.10, Patient-Aligned Care Teams, regarding care coordination.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director provide access to care at the Mat-Su VA Community Based Outpatient Clinic in accordance with Veterans Health Administration policy and provider recommendations for follow-up.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement a peer review process consistent with Veterans Health Administration policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the Veterans Integrated Service Network Director ensure the System Director perform peer review and consult regional counsel as appropriate for the cases identified in this report.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director implement a provider evaluation process consistent with Veterans Health Administration policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director strengthen processes for committee reporting to align with Veterans Health Administration Directive 1026, Enterprise Framework for Quality, Safety, and Value, and system bylaws.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2016
We recommended that the Veterans Integrated Service Network Director ensure that the System Director assess the culture, morale, and leadership issues identified in this report, and take appropriate action as necessary.
Healthcare Inspection – Alleged Quality of Care Issues at the Community Based Outpatient Clinic, Casa Grande, AZ
|
14-04260-395

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended that the Southern Arizona VA Health Care System Director ensure that same day access appointments and post hospitalization follow-up appointments at the Casa Grande Community Based Outpatient Clinic are triaged appropriately and timely.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2015
We recommended that the Southern Arizona VA Health Care System Director ensure that processes are strengthened to improve telephone appointment scheduling practices.
Improper Use of Title 38 Section 8153 Contracts to Fund Educational Costs of the Graduate Medical Education Programs of Affiliated Schools of Medicine
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14-04259-409

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/7/2015
We recommend that the Interim Under Secretary for Health rescind VHA Handbook 1400.10.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/7/2015
We recommend that the Interim Under Secretary for Health terminate existing contracts for indirect educational costs awarded under the guidance of VHA Handbook 1400.10.
Healthcare Inspection – Alleged Quality of Care Concerns, Gene Taylor Community Based Outpatient Clinic, Mount Vernon, Missouri
|
14-04547-398

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2015
We recommended that the Interim Under Secretary for Health review documentation requirements of Veterans Health Administration Handbook 1907.01 and determine whether the documentation requirements support the obligations placed on VA primary care providers by Veterans Health Administration Directive 2009-038.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Veterans Health Care System of the Ozarks Director ensure that providers evaluate patients and coordinate care provided in the community in accordance with Veterans Health Administration¿s dual care policy.
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