Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00029-183 | Leaders’ Failure to Resolve Cardiology Department Challenges at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana | Hotline Healthcare Inspection | ||
1 The Richard L Roudebush VA Medical Center Director ensures the Chief of Staff, chief of medicine, and chief of cardiology, in consultation with the National Cardiology Program Office, reevaluate the Cardiology Department and establish and implement a long-term service plan that includes cardiology services and cardiologist and specialty cardiologist staffing levels.
Closure Date:
2 The Richard L Roudebush VA Medical Center Director provides the chief of cardiology with the dedicated resources needed to develop, implement, and sustain Cardiology Department changes.
Closure Date:
3 The Veterans Integrated Service Network Director provides oversight of the Richard L Roudebush VA Medical Center Director’s development and implementation of a long-term Cardiology Department plan, monitors the department’s progress, and ensures changes are sustained.
Closure Date:
4 The Veterans Integrated Service Network Director ensures the Richard L Roudebush VA Medical Center Director continues to strengthen and maintain the Cardiology Department’s relationship with the university affiliate, including residency and fellow cardiology programs and joint efforts to recruit cardiologists.
Closure Date:
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| 22-03543-151 | The Fiduciary Program Needs to Verify the Prompt Return of Deceased Beneficiaries’ Funds to VA | Review | ||
1 The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.
Closure Date:
2 The Pension and Fiduciary Service considers reimplementing the procedural requirement to verify the disbursement of VA-derived funds to deceased beneficiaries’ estates when a valid will or heir exists.
Closure Date:
3 The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.
Closure Date:
4 The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.
Closure Date:
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| 22-01511-174 | Concern with Veterans Health Administration’s Lung Cancer Screening Program Requirements | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.
Closure Date:
2 The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.
Closure Date:
3 The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.
Closure Date:
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| 22-00069-177 | Comprehensive Healthcare Inspection of the Lebanon VA Medical Center in Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
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| 22-00068-171 | Comprehensive Healthcare Inspection of the Butler VA Health Care System in Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager initiates an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
2 The Executive Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.
Closure Date:
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| 22-02485-168 | Deficiencies in Communication for a Patient with a Spinal Cord Injury at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director establishes a process to optimize communication between the Surgery Service and the Spinal Cord Injury Service when providing care to spinal cord injury patients.
Closure Date:
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| 22-00064-172 | Comprehensive Healthcare Inspection of the VA Palo Alto Health Care System in California | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The System Director determines any additional reasons for noncompliance and ensures staff conduct required preventive maintenance on medical equipment.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and ensures only authorized staff have access to medications.
Closure Date:
4 The System Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.
Closure Date:
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| 22-02797-169 | Concerns with Access to Care in the Outpatient Mental Health Clinic at the Charles George VA Medical Center in Asheville, North Carolina | Hotline Healthcare Inspection | ||
1 The Charles George VA Medical Center Director evaluates processes for mental health consult scheduling, including community care referrals, and ensures patients are offered timely appointments, per Veterans Health Administration policies.
Closure Date:
2 The Charles George VA Medical Center Director confirms outpatient Mental Health staff receive education about Veterans Health Administration and facility policies related to mental health consult processes, including timeliness and community care consults.
Closure Date:
3 The Charles George VA Medical Center Director evaluates the design, staffing, and implementation of the Behavioral Health Interdisciplinary Program to ensure the program supports timely access to mental health care and takes action as appropriate.
Closure Date:
4 The Charles George VA Medical Center Director confers with Mental Health leaders to identify, track, and mitigate barriers to staff retention and takes appropriate action.
Closure Date:
5 The Charles George VA Medical Center Director ensures Mental Health leaders review current communication practices within Mental Health operations, in accordance with Veterans Health Administration High Reliability Organization values and principles and considers the use of VHA resources, such as the National Center for Organization Development.
Closure Date:
6 The Charles George VA Medical Center Director ensures Mental Health leaders educate Mental Health clinic staff on the role of the suicide prevention team in patient care.
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7 The Charles George VA Medical Center Director reviews and evaluates processes for monitoring and managing Veterans Health Administration-required follow-up care for patients with high risk for suicide patient record flags, including scheduling and tracking of required follow-up appointments, and monitoring compliance.
Closure Date:
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| 22-00231-176 | Comprehensive Healthcare Inspection of the San Francisco VA Health Care System in California | Comprehensive Healthcare Inspection Program | ||
1 The Health Care System Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews, and supervisors ensure implementation of those actions.
Closure Date:
3 The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews Ongoing Professional Practice Evaluation results and documents privileging decisions in the meeting minutes.
Closure Date:
5 The Associate Director for Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures staff check supply rooms for expired supplies and discard them.
Closure Date:
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| 22-00054-158 | Comprehensive Healthcare Inspection of the Southern Arizona VA Health Care System in Tucson | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.
Closure Date:
2 The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete environment of care inspections in patient care areas at the required frequency and document the inspection results.
Closure Date:
3 The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee tracks environment of care inspection deficiencies until they are resolved.
Closure Date:
4 The Director determines any additional reasons for noncompliance and ensures staff post signage in all areas where potentially infectious materials are present.
Closure Date:
5 The Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and furnishings and equipment safe and in good repair.
Closure Date:
6 The Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.
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15770