OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Oversight Reports

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Facility Director ensures patient transfer data for transfers out of the facility are collected, analyzed, and reported to an identified quality oversight committee and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record, and the Chief of Staff monitors providers’ compliance.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representation by all required disciplines, and demonstrates integration with the facility quality improvement program, and the Chief of Staff monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Review Team completes the required annual reviews for the community nursing homes and monitors managers’ compliance.

No. 10   to Veterans Health Administration (VHA)

The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration and monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees in units 5A and 5D conduct and document daily resident room inspections for unsecured medications and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures inter-facility patient transfer data are analyzed and reported to a quality oversight committee as part of the facility’s quality management program and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director ensures required team members participate in environment of care rounds and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures the locked mental health unit’s seclusion room bed is secured to the floor.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures that locked mental health unit employees and members of the Interdisciplinary Safety Inspection Team complete the required training for the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Associate Director monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures that providers assess for patients’ previous adverse experiences with sedation or anesthesia prior to performing moderate sedation procedures and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures that clinical team members conduct timeouts using a checklist with all the required elements prior to performing moderate sedation procedures and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures Medicine Service clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures quality assurance data for the anticoagulation management program are collected, analyzed, and reported quarterly at Pharmacy and Therapeutics Committee meetings and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and refer patients prescribed direct-acting oral anticoagulants to the anticoagulation clinic and monitors clinicians’ compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff requires that clinical managers include in the competency assessments of employees actively involved in the anticoagulant program knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy, and the Chief of Staff monitors clinical managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures inter-facility patient transfer data are analyzed and reported and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, providers consistently complete VA Forms 10-2649A and 10-2649B as required by Veterans Integrated Service Network policy and monitors providers’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information, and the Chief of Staff monitors providers’ compliance.

No. 8   to Veterans Health Administration (VHA)

The Associate Director for Facilities and Human Resources ensures the VA Police Service consistently participates on environment of care rounds and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Associate Director for Facilities and Human Resources ensures locked mental health unit panic alarm testing documentation includes VA Police Service response time and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures that a risk assessment is completed when a locked mental health unit patient is using an electrical or mechanical hospital bed and that the room containing the bed is locked when not in use, and the Associate Director for Patient Care Services monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The Facility Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Facility Director monitors compliance.

No. 12   to Veterans Health Administration (VHA)

The Chief of Staff ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events for all areas administering moderate sedation are reported to and trended by the Surgical, Procedural, Operative, and Therapeutic Committee and monitors compliance.

No. 13   to Veterans Health Administration (VHA)

The Chief of Staff ensures providers include a review of abnormalities of major organ systems; an airway assessment; and a review of alcohol, tobacco, or substance use or abuse in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.

No. 14   to Veterans Health Administration (VHA)

The Chief of Staff ensures providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and monitors providers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures revision of local policy to specify the Quality and Performance Council as the senior-level committee responsible for key quality, safety, and value functions and co-chairs this committee.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors physician advisors’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that anticoagulation management program quality assurance data are collected, analyzed, and reported quarterly at the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical managers include anticoagulation-specific elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures inter-facility patient transfer data are collected, reported, and analyzed as part of the facility’s quality management program and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures transfer notes written by acceptable designees include a staff/attending physician countersignature and monitors acceptable designees’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate in environment of care rounds and monitors team members’ compliance.

No. 8   to Veterans Health Administration (VHA)

The Associate Director ensures that VA Police perform and document system-wide panic alarm testing at the Salina community based outpatient clinic and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff ensures providers include an airway assessment in the history and physical examination and/or pre-sedation assessment and monitors providers’ compliance.

No. 10   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinicians perform post-procedure assessments of patient pain level and monitors clinicians’ compliance.

No. 11   to Veterans Health Administration (VHA)

The Facility Director ensures the Community Nursing Home Oversight Committee continues to meet at least quarterly and monitors compliance.

No. 12   to Veterans Health Administration (VHA)

The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.

No. 13   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.

No. 14   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor social workers’ and registered nurses’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, providers consistently include patient or surrogate informed consent, medical and/or behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and monitors providers’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures the team members responsible for comprehensive EOC rounds consistently participate and use the Comprehensive Environment of Care Assessment and Compliance Tool to document results of those rounds and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers perform suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of the referral and monitors providers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinicians consistently provide patient education specific for newly prescribed anticoagulant medications and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating warfarin and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility’s capacity and monitors providers’ compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors providers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees document details of the observations and deficiencies identified during monthly self-inspections, submit work orders for all items needing repair, and document corrective actions taken, and the Chief of Staff monitors employees’ compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees consistently conduct and document weekly contraband inspections and monitors employees’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Associate Director ensures that Mental Health Residential Rehabilitation Treatment Program managers ensure that all doors not considered as the main point of entry have audible alarms and monitors managers’ compliance.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and refer them and monitors providers’ compliance.

No. 10   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers complete diagnostic evaluations within 30 days for patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

No. 11   to Veterans Health Administration (VHA)

The Chief of Staff ensures that resident physicians are assigned and granted the correct user class computer option and that clinical managers review and monitor residents’ progress notes to ensure that resident supervision documentation meets requirements, and the Chief of Staff monitors managers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data at least every 6 months and monitors managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures that facility managers maintain a safe and clean environment in all patient care areas and monitors the managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by the medical staff and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures social workers and registered nurses conduct alternating, cyclical clinical visits with the required frequency and monitors their compliance.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director ensures a safe respiratory environment for patients and employees in the Community Living Center units and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Facility Director requires the Quality, Safety, and Value Council to document meeting minutes that include evidence of the review and analysis of aggregated data, identification of opportunities for improvement, implementation of corrective actions, and evaluation of effectiveness of the actions and monitors the Quality, Safety, and Value Council’s compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures that for patients transferred out of the facility, sending nurses document transfer assessments/notes and monitors the nurses’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information and monitors providers’ compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures access to sterile supplies at the Gallipolis community based outpatient clinic is restricted and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures medical (biohazardous) waste stored for pick-up at the Gallipolis community based outpatient clinic is secured and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Oversight Committee includes a representative from acquisitions.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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2/24/2018 3:34:20 AM


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