Recommendations
2085
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-00349-10 | Review of Quality of Care for Patients Seeking Acute Mental Health Care at the Lexington VA Healthcare System in Kentucky | Hotline Healthcare Inspection | ||
1 The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.
2 The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.
3 The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.
4 The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.
5 The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2’s documentation in Patient 2’s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.
6 The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.
7 The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.
8 The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.
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| 25-03462-12 | Management of Personally Owned Insulin Pumps for Patients at Risk for Suicide in Emergency Departments and Inpatient Units | National Healthcare Review | ||
1 The Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.
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| 24-03416-237 | Healthcare Facility Inspection of the Minneapolis VA Health Care System in Minnesota | Healthcare Facility Inspection | ||
1 The Associate Director ensures staff make feminine hygiene products available in public women’s and unisex restrooms.
2 The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.
3 Biomedical staff indicate inspection dates on all equipment.
Closure Date:
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| 25-00196-05 | Healthcare Facility Inspection of the Miami VA Healthcare System in Florida | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.
2 The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers’ recommendations.
3 The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.
4 The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.
5 The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.
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| 25-00197-236 | Healthcare Facility Inspection of the VA Tennessee Valley Healthcare System in Nashville | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff perform preventive maintenance in accordance with manufacturers’ guidelines and clearly define staff responsibilities.
Closure Date:
2 Executive leaders continue to recruit a permanent chief of biomedical engineering and implement processes to prevent repeat environment of care findings.
Closure Date:
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| 25-02447-08 | Review of Community Care Utilization, Delivery of Timely Care, and Provider Qualifications at the VA Boston Healthcare System in Massachusetts, Fiscal Year 2024 | National Healthcare Review | ||
1 The VA Boston Healthcare System Director assesses the timeliness of appointment setting for VA direct and community care referrals and ensures facility staff establish appointments within required time frames.
2 The VA Boston Healthcare System Director reviews consult management practices and ensures the proper use of consults for VA direct care referrals.
3 The VA Boston Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.
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| 24-03531-09 | Review of Response to Changes in a Patient’s Condition and Quality Reviews at the VA Greater Los Angeles Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patient’s care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.
2 The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessment’s administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses’ adherence; and conducts audits to ensure improved and sustained compliance.
3 The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients’ on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.
4 The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.
5 The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administration’s nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.
6 The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.
7 The VA Greater Los Angeles Healthcare System Director confirms that facility staff made reasonable efforts to conduct an institutional disclosure with the patient’s family.
Closure Date:
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| 24-03205-235 | Healthcare Facility Inspection of the VA Louisville Healthcare System in Kentucky | Healthcare Facility Inspection | ||
1 The Executive Director oversees improvements to the telephone system to ensure identified vulnerabilities are addressed.
2 Facility leaders ensure exit signs lead to an exit.
3 Facility leaders install detectable warning surfaces anywhere a walkway transitions into a roadway.
4 The Executive Director ensures staff keep patient care areas clean and safe.
5 Facility leaders ensure staff conduct a risk assessment for electrical cord management to identify and implement any needed improvements.
6 The Executive Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present and store clean and dirty items separately.
7 The Executive Director ensures prompt disposal of biohazardous waste.
8 Facility leaders ensure staff conduct a risk assessment on liquid nitrogen use and storage, to include devices in exam rooms, and implement changes accordingly.
9 The Executive Director ensures the Comprehensive Environment of Care Committee identifies at least one facility-specific environment of care trend and establishes a performance improvement plan, including outcome measures, to address it.
10 Facility leaders ensure staff develop service-level workflows for the communication of test results for each service.
11 Facility leaders review the test result communication policy to ensure it complies with the VHA requirement for communicating critical results outside of normal business hours.
12 Facility leaders develop a formal process for staff to track performance metrics for test result communication, implement improvement actions, and report compliance to an appropriate oversight committee.
13 Facility leaders manage panel sizes to ensure patients have timely access to high-quality care.
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| 24-00607-241 | Healthcare Facility Inspection of the VA Detroit Healthcare System in Michigan | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff fix or replace damaged furnishings to allow effective cleaning and disinfection.
2 Executive leaders ensure staff place paper maps at information desks to assist veterans in navigating the facility.
Closure Date:
3 Executive leaders ensure staff store clean equipment in a sanitary environment.
4 Executive leaders ensure hallways and exits are free from obstruction.
5 Executive leaders ensure staff remove defective equipment from clinical areas to prevent use.
6 Executive leaders ensure staff have computer screen privacy filters to protect patients’ personally identifiable information.
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| 24-00392-240 | Inspection of Midwest District 3 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.
2 The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.
3 The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint disposition and related RCSNet documentation.
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15061