Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00674-153 | Opportunities Exist to Better Integrate Health-Related Social Needs and Social Determinants of Health into Discharge Assessment and Planning | National Healthcare Review | ||
1 The Under Secretary for Health considers the need for a national policy establishing the inclusion of social determinants of health/health-related social needs into discharge assessment and planning.
Closure Date:
2 The Under Secretary for Health considers the implementation of a standardized electronic health record template, such as the Assessing Circumstances and Offering Resources for Needs tool, that includes the assessment of social determinants of health/health-related social needs of hospitalized patients.
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3 The Under Secretary for Health evaluates barriers to assessing social determinants of health/health-related social needs when patients are discharged from VA medical centers.
Closure Date:
4 The Under Secretary for Health promotes the use of health equity tools across VA medical centers
Closure Date:
5 The Under Secretary for Health promotes the establishment of partnerships of VA medical centers with community resources to address social determinants of health/health-related social needs.
Closure Date:
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| 23-00102-150 | Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures staff maintain a safe environment by keeping walls in good repair.
Closure Date:
2 The Associate Director ensures staff check over-the-door alarms in the inpatient mental health unit according to the manufacturer’s guidelines.
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3 The Associate Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
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| 23-00119-156 | Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.
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3 The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.
Closure Date:
4 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
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5 The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.
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| 23-00104-134 | Comprehensive Healthcare Inspection of the Central Virginia VA Health Care System in Richmond | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations for all Level 3 peer reviews to providers and ensure they implement the improvement actions.
Closure Date:
2 The Chief of Staff ensures the Medical Executive Council documents its review of licensed independent practitioners’ professional practice evaluations and recommend privileges based on the results.
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3 The Executive Director ensures staff store reusable medical equipment in temperature- and humidity-controlled storage locations.
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4 The Associate Director ensures staff keep storage rooms and areas used by patients clean and safe.
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5 The Chief of Staff limits medication access to approved staff members.
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6 The Associate Director ensures all toilet rooms within proximity to areas where pelvic examinations are performed, and all women’s, unisex, and family public restrooms have feminine hygiene products available at no cost.
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| 23-00540-146 | Comprehensive Healthcare Inspection Program and Care in the Community Report: Mammography Services and Breast Cancer Care | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with the National Oncology Program and Veterans Integrated Service Network directors, ensure facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.
Closure Date:
2 The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.
Closure Date:
3 The Under Secretary for Health, Veterans Integrated Service Network directors, and facility leaders ensure staff enter data into the local cancer registry database in a timely manner.
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| 23-00107-135 | Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs incorporate service-specific criteria in professional practice evaluations.
Closure Date:
2 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00098-151 | Comprehensive Healthcare Inspection of the VA Nebraska-Western Iowa Health Care System in Omaha | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
Closure Date:
2 The Chief of Staff ensures service chiefs document Focused Professional Practice Evaluation results in licensed independent practitioners’ profiles.
Closure Date:
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| 23-01602-147 | Increased Utilization of Primary Care in the Community by the VA Loma Linda Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director confirms that a mechanism is in place to monitor primary care patient aligned care team staffing and panel sizes at the non-VHA-operated clinics to ensure staff are available to care for enrolled patients.
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2 The VA Loma Linda Healthcare System Director directs a review be done of VA Loma Linda Healthcare System adherence to Veterans Health Administration metrics for the processing and scheduling of community care consults and, if not met, determines the reasons for noncompliance, creates an action plan to address deficiencies, and monitors for compliance.
Closure Date:
3 The VA Loma Linda Healthcare System Director conducts an assessment of the community- based outpatient clinic steering committee to ensure consistent oversight of quality of care and staffing levels for all of the VA Loma Linda Healthcare System’s VA outpatient clinics.
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| 23-00108-149 | Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.
Closure Date:
2 The Associate Director ensures staff keep patient care areas safe and clean.
Closure Date:
3 The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.
Closure Date:
4 The Director ensures staff maintain a safe environment in the mental health inpatient unit.
Closure Date:
5 The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.
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6 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
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| 22-03941-144 | Inspection of Southeast District 2 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
2 The District Director identifies reasons for noncompliance with timely documentation requirements of high-risk client contacts and outcomes in the electronic record and High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.
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3 The Readjustment Counseling Service Chief Officer ensures the High Risk Suicide Flag SharePoint site functions as intended and includes accurate data.
Closure Date:
4 The District Director and zone leaders identify reasons for noncompliance, ensure Readjustment Counseling Service policy confidentiality requirements are followed when collaborating care with the support VA medical facility for shared clients at high risk for suicide, and monitor compliance across all zone vet centers.
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5 The District Director identifies reasons for noncompliance with consultation requirements for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures consultation requirements are met; and monitors compliance.
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6 The District Director identifies reasons for noncompliance; ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director identifies reasons for noncompliance, ensures clients are provided a copy of their completed safety plan as required, and monitors compliance across all zone vet centers.
Closure Date:
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15303