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)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinical staff offer HIV screening as part of routine medical care and that managers monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians document informed consent for HIV testing and that managers monitor for compliance. VA Office

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the clinic manager ensures the risk of infection is minimized when storing and disposing of medical waste at the Childress VA Clinic.

No. 2   to Veterans Health Administration (VHA)

We recommended that the clinic manager ensures that exit routes are unobstructed at the Childress VA Clinic.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.

No. 5   to Veterans Health Administration (VHA)

We recommended that staff at the Childress VA Clinic protect and secure patient-identifiable information.

No. 6   to Veterans Health Administration (VHA)

We recommended that the Childress VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.

No. 7   to Veterans Health Administration (VHA)

We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.

No. 8   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.

No. 9   to Veterans Health Administration (VHA)

We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.

No. 10   to Veterans Health Administration (VHA)

We recommended that clinicians consistently provide and document interventions for clinically significant abnormal laboratory results.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures that fire drills and fire drill critiques are conducted at least every 12 months at the Winsted VA Clinic.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Winsted VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.

No. 3   to Veterans Health Administration (VHA)

We recommended that providers sign Home Telehealth assessments and treatment plans.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.

No. 5   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the facility revise the local policy to include specific procedures for the identification of individuals entering the CBOCs.

No. 2   to Veterans Health Administration (VHA)

We recommended that the facility ensure a safe work environment with adequate security coverage and incident responses at the Auburn Gresham VA Clinic.

No. 3   to Veterans Health Administration (VHA)

We recommend that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.

No. 4   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.

No. 5   to Veterans Health Administration (VHA)

We recommended that the facility update its template to ensure providers’ plans of care and disposition are accurately documented for patients with positive PTSD screens.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that providers sign Home Telehealth assessments and treatment plans.

No. 2   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that managers ensure that Milledgeville VA Clinic staff participate in emergency management training and exercises.

No. 2   to Veterans Health Administration (VHA)

We recommended that the clinic manager ensures that Milledgeville VA Clinic and contracted employees receive the required hazardous communications training.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Milledgeville VA Clinic manager ensures that there are no expired injectable medication vials.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.

No. 5   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.

No. 6   to Veterans Health Administration (VHA)

We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.

No. 7   to Veterans Health Administration (VHA)

We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that employees at the Gardena VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.

No. 2   to Veterans Health Administration (VHA)

We recommended that managers ensure that staff at the Gardena VA Clinic participate in emergency management training and exercises.

No. 3   to Veterans Health Administration (VHA)

We recommended that the clinic manager ensures that Gardena VA Clinic employees receive the required hazardous communications training.

No. 4   to Veterans Health Administration (VHA)

We recommended that the clinic manager review the Gardena VA Clinic’s hazardous materials inventory twice within a 12-month period.

No. 5   to Veterans Health Administration (VHA)

We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.

No. 6   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.

No. 7   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that managers monitor hand hygiene compliance at the Monroe County VA Clinic.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures annual review of the Hazard Vulnerability Assessment for the Monroe County VA Clinic.

No. 3   to Veterans Health Administration (VHA)

We recommended that the clinic manager ensures that sterile commercial supplies at the Monroe County VA Clinic are not expired.

No. 4   to Veterans Health Administration (VHA)

We recommended that the clinic manager reviews the Monroe County Clinic's hazardous materials inventory twice within a 12-month period.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Monroe County VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.

No. 6   to Veterans Health Administration (VHA)

We recommended that clinicians document contact with patients to evaluate suitability for Home Telehealth services.

No. 7   to Veterans Health Administration (VHA)

We recommended that providers sign Home Telehealth assessments and treatment plans.

No. 8   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results within 14 days.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that employees at the Afton CBOC receive annual training on the Exposure Control Plan for Bloodborne Pathogens.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures that a policy/procedure is in place for the identification of individuals entering the Afton CBOC.

No. 3   to Veterans Health Administration (VHA)

We recommended that the clinic manager ensures that Afton CBOC employees receive the required hazardous communications training.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensures there is a policy/procedure for the cleaning and disinfection of telehealth equipment at the Afton CBOC.

No. 5   to Veterans Health Administration (VHA)

We recommended that clinicians document assessments and treatment plans for Home Telehealth patients.

No. 6   to Veterans Health Administration (VHA)

We recommended that providers sign Home Telehealth assessments and treatment plans.

No. 7   to Veterans Health Administration (VHA)

We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.

No. 8   to Veterans Health Administration (VHA)

We recommended that clinicians consistently notify patients of their laboratory results within the timeframe required by VHA.

No. 9   to Veterans Health Administration (VHA)

We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.

No. 10   to Veterans Health Administration (VHA)

We recommended that acceptable providers document plans of care and disposition for patients with positive PTSD screens.

No. 11   to Veterans Health Administration (VHA)

We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.

No. 12   to Veterans Health Administration (VHA)

We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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2/21/2018 8:51:11 PM


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