Recommendations
2060
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00229-15 | Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System in Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff recommends continuation of privileges based on Ongoing Professional Practice Evaluation results.
Closure Date:
4 The Assistant Director for Efficiency and Improvement evaluates and determines any additional reasons for noncompliance and ensures managers comply with inpatient mental health unit environmental safety requirements.
Closure Date:
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| 22-00072-16 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 4: VA Healthcare in Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials files and recommends VA appointments for physicians with a history of licensure action.
Closure Date:
2 The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.
Closure Date:
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| 22-02667-09 | Comprehensive Healthcare Inspection of the Iowa City VA Health Care System in Iowa | Comprehensive Healthcare Inspection Program | ||
1 The System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete adverse event investigations within seven days and document appropriately in the Joint Patient Safety Reporting system, or the Patient Safety Manager monitors the investigations until they are completed.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures managers keep areas used by patients clean, safe, and suitable for the care, treatment, and services provided.
Closure Date:
6 The System Director determines any additional reasons for noncompliance and ensures staff monitor and document VA police response times to panic alarm testing in the Mental Health Inpatient Unit on a regular basis.
Closure Date:
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| 22-04135-06 | Comprehensive Healthcare Inspection of the Mann-Grandstaff VA Medical Center in Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures the Peer Review Committee submits accurate peer review summary analysis data quarterly to the Health Care Delivery Council.
Closure Date:
2 The Medical Center Director ensures the Health Care Delivery Council reviews the Peer Review Committee’s summary analysis quarterly and determines actionable items.
Closure Date:
3 The Medical Center Director ensures employees comply with safe work practices to eliminate or minimize exposure to potentially infectious materials.
Closure Date:
4 The Medical Center Director ensures the Inpatient Unit Nurse Manager for the medical/surgical intensive care unit restricts access to clean and sterile storerooms to authorized personnel.
Closure Date:
5 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to local mental health leaders and quality management staff.
Closure Date:
6 The Medical Center Director ensures providers complete Comprehensive Suicide Risk Evaluations following patients’ positive suicide risk screens.
Closure Date:
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| 22-03599-07 | Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director ensures that providers are educated on conducting clinical disclosures and documenting the discussion in the patient’s electronic health record when harm is determined to be more than minor.
Closure Date:
2 The Phoenix VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, and ensures the current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
Closure Date:
3 The Phoenix VA Health Care System Director confirms that the Peer Review Committee record formal discussions in meeting minutes, including discussion specific to changes in rating levels in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
4 The Phoenix VA Health Care System Director makes certain adverse events or close calls are entered into the Joint Patient Safety Reporting system and the facility patient safety manager completes reviews, assigns a safety assessment code score, and conducts root cause analyses in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
5 The Phoenix VA Health Care System Director evaluates the process for the communication of abnormal test results to patients and ensures that ordering providers or designees provide timely notification to patients in a manner that informs patients of the results in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
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| 22-00416-10 | Improvements Needed in Lung Cancer Screening Through Use of Community Care | National Healthcare Review | ||
1 The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure timely reporting of results to VA facilities consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.
2 The Under Secretary for Health ensures the Veterans Health Administration Office of Integrated Veteran Care reevaluates whether the minimum number of attempts prior to administratively closing consults for community care lung cancer screening with low dose computed tomography scans should continue as an ongoing process, and takes action as warranted.
Closure Date:
3 The Under Secretary for Health reiterates expectations for providers to comply with the Veterans Health Administration directive regarding communication of test results to patients, including required time frames.
Closure Date:
4 The Under Secretary for Health evaluates whether low-dose computed tomography lung cancer screenings sent through VA community care have quality assurance practices in place that ensure follow-up on scan results consistent with other cancer screenings that are sent through the community care program and takes corrective action to address any identified deficiencies.
Closure Date:
5 The Under Secretary for Health facilitates a comprehensive review of the patient cases provided by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.
Closure Date:
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| 23-00092-12 | Comprehensive Healthcare Inspection of the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges evaluate licensed independent practitioners on an ongoing basis.
Closure Date:
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| 22-00237-05 | Comprehensive Healthcare Inspection of the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 The Director determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain medical supplies that are not contaminated, damaged, expired, or recalled.
Closure Date:
4 The Chief of Staff or Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff post notices in treatment areas with overt recording announcing the area is subject to photography or video recording.
Closure Date:
5 The Director evaluates and determines the reasons for noncompliance and ensures staff create or update safety plans for patients with a positive suicide risk screen who are determined safe to discharge home from the Emergency Department.
Closure Date:
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| 23-00006-03 | Comprehensive Healthcare Inspection of the Royal C. Johnson Veterans' Memorial Hospital in Sioux Falls, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures designated staff complete a 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.
Closure Date:
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| 22-03522-209 | VBA Generally Helped Veterans Obtain Damaged or Destroyed Records | Audit | ||
1 Establish a process to identify and track veterans’ files for those determined to have fire-damaged or destroyed records, such as adding a corporate flash, and update the Adjudication Procedural Manual indicating when veterans service representatives should apply such procedures.
Closure Date:
2 Instruct veterans service representatives on the process for requesting service treatment and military service records for fire-related records, which includes more specific guidance on what information is required for the National Personnel Records Center to locate veterans’ records.
Closure Date:
3 Ensure veterans service representatives are made aware of and follow steps as outlined in the manual for when to send required forms and conduct follow-up contact with veterans.
Closure Date:
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14935