Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-06848-209 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 15: VA Heartland Network in Kansas City, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that annual utilization management program summary reviews are completed for each facility.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact submits an annual Pain Management Strategy implementation and progress report.
Closure Date:
3 The Network Director determines the reason for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact establishes a pain committee
Closure Date:
4 The Network Director determines the reasons for noncompliance and makes certain that the lead Women Veterans Program Manager executes interdisciplinary strategic planning activities for comprehensive women’s health care.
Closure Date:
5 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager provides quarterly updates to the Network Director or Chief Medical Officer.
Closure Date:
6 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager conducts yearly site visits at each facility within the Veterans Integrated Service Network.
Closure Date:
7 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager develops educational programs and/or resources for needs identified from the staff education gap assessment
Closure Date:
8 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager analyzes women veterans’ access and satisfaction data.
Closure Date:
9 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager tracks maternity care outcome data.
Closure Date:
10 The Network Director determines the reasons for noncompliance and ensures that facility corrective action plans are developed and submitted within 30 days of each completed inspection.
Closure Date:
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| 19-07062-230 | Site Visit Program Can Do More to Improve Nationwide Claims Processing | Review | ||
1 The OIG recommended that the under secretary for benefits direct the Compensation Service to formalize the Hot Topics list into an annual report submitted to the Office of Field Operations detailing all recurring deficiencies and action items identified throughout the inspection year from its site visit program.
Closure Date:
2 The OIG recommended that the under secretary for benefits require the Office of Field Operations to initiate a recurring plan to correct all recurring deficiencies and action items identified by the Compensation Service throughout the inspection year from its site visit program annual report.
Closure Date:
3 The OIG recommended that the under secretary for benefits direct the Office of Field Operations to establish a follow-up process to monitor compliance with the new requirement and hold regional office managers accountable for making corrections and addressing action items in a timely manner.
Closure Date:
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| 19-06872-199 | Comprehensive Healthcare Inspection of the Robert J. Dole VA Medical Center in Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analysis actions are implemented and properly documented in the VHA Patient Safety Information System.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that the Patient Safety Manager or designee provides an annual patient safety report to medical center leaders.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers consistently collect and review ongoing professional practice evaluation data.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Professional Standards Board meeting minutes consistently reflect the review of professional practice evaluation results when recommending continuation of privileges.
Closure Date:
10 The Chief of Staff determines reason(s) for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
Closure Date:
11 The Chief of Staff determines reason(s) for noncompliance and ensures the departing licensed healthcare professional’s first- or second-line supervisor appropriately signs the exit review form.
Closure Date:
12 The Associate Director determines reason(s) for noncompliance and ensures that patient care supply areas are properly designated, and adequate temperature and humidity controls are continuously monitored and maintained.
Closure Date:
13 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center.
Closure Date:
14 The Chief of Staff determines the reason(s) for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics to the medical center.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
Closure Date:
17 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
Closure Date:
18 The Chief of Staff determines reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame and document the patient’s preference for telephonic follow-up, if warranted.
Closure Date:
19 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete safety plans in a timely manner and that all required elements—including firearm and opioid safety—are assessed for patients with High Risk for Suicide Patient Record Flags.
Closure Date:
20 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures clinical and nonclinical staff receive annual suicide prevention refresher training.
Closure Date:
21 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and appoints a multidisciplinary committee responsible for life-sustaining treatment decision reviews that includes representatives from three or more different disciplines.
Closure Date:
22 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
Closure Date:
23 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that Sterile Processing Services reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
24 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services maintain required airflow parameters for areas where reusable medical equipment is reprocessed.
Closure Date:
25 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that staff avoid eating, drinking, and/or storing food items in areas where decontamination, sterilization, or clean/sterile storage occurs.148
Closure Date:
26 The Associate Director for Patient Care Services determines reason(s) for noncompliance and ensures that staff properly store endoscopes.
Closure Date:
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| 20-00077-211 | Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center in Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a minimum of 80 percent of inpatient utilization management reviews are completed.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
Closure Date:
3 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that the Medical Executive Council documents conclusions and recommendations for continuation of privileges that are based on focused professional practice evaluation results.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that first- or second-line supervisors complete provider exit review forms within seven calendar days of providers’ departure from the medical center.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that service leaders immediately report a provider’s failure to meet generally accepted standards of practice to state licensing boards
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete an aberrant behavior risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
Closure Date:
7 The Chief of Staff determines the reasons for noncompliance and makes certain that clinicians document justification for concurrent opioid and benzodiazepine medication therapy.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians follow up with patients within the required time frame after initiating long-term opioid therapy.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider follow-up with patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
Closure Date:
12 The Medical Center Director determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
Closure Date:
13 The Chief of Staff determines the reasons for noncompliance and ensures that mental health providers consistently contact or attempt to contact high-risk patients who miss mental health or substance abuse appointments and properly document those efforts.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that providers complete safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
Closure Date:
15 The Chief of Staff evaluate and determines any additional reason for noncompliance and makes certain that suicide prevention safety plans include all required elements.
Closure Date:
16 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff complete suicide risk and intervention training within 90 days of entering their position and annual suicide prevention refresher training thereafter.
Closure Date:
17 The Medical Center Director determines the reasons for noncompliance and makes certain that a multidisciplinary life-sustaining treatment decisions committee is established to review all proposed plans.
Closure Date:
18 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each site of care has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
Closure Date:
19 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend the Women Veterans Health Committee meetings.
Closure Date:
20 The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
Closure Date:
21 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
22 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Closure Date:
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| 19-06873-210 | Comprehensive Healthcare Inspection of the VA St. Louis Health Care System in Missouri | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures improvement actions recommended by the Quality Executive Board are fully implemented and improvement changes are monitored.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
Closure Date:
3 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee consistently implements improvement actions arising from root cause analysis activities.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
Closure Date:
7 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the healthcare system.
Closure Date:
8 The Associate Director determines the reasons for noncompliance and ensures mental health unit cameras are reconfigured to eliminate blind spots.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to beginning long-term opioid therapy.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy and assess intervention effectiveness.
Closure Date:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Pain Committee monitors the quality of pain assessment, effectiveness of pain management interventions, and opportunities for improvements.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator delivers at least five outreach activities each month.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
Closure Date:
16 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
Closure Date:
17 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings and that the committee reports to an executive leadership board.
Closure Date:
18 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that gastroenterology staff test at least 10 percent of reprocessed endoscopes for bioburden and testing to include each endoscope model.
Closure Date:
19 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 20-01129-220 | Improving VA and Select Community Care Health Information Exchanges | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews the barriers related to the utilization of VA Direct and ensures the Veterans Health Information Exchange Program Office increases the number of facilities using VA Direct as a secure option to share health information.
Closure Date:
2 The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office evaluates the VA Exchange and VA Direct training and education programs and increases accessibility to Veterans Health Administration staff, community partners, and veterans.
Closure Date:
3 The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office increases the number of community partners, including more state exchanges and other Health Information Exchange stakeholders, to facilitate the expansion of bidirectional health information exchange.
Closure Date:
4 The Under Secretary for Health confirms the Veterans Health Information Exchange Program Office evaluates the performance work statements of the Veterans Health Information Exchange community coordinators and ensures compliance with the scope of work.
Closure Date:
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| 19-08095-198 | Accuracy of Disability Benefit Evaluations for Veterans' Service-Connected Heart Diseases | Review | ||
1 We recommended the under secretary for benefits implement a plan to incorporate the system-generated instructions for medical providers directly into the heart disability questionnaire (instead of separately on the examination request) and determine whether additional revisions are necessary to ensure medical providers’ findings are sufficient for evaluation purposes.
Closure Date:
2 We recommended the under secretary for benefits implement a plan to ensure medical providers who complete heart disability benefits questionnaires are made aware of common problem areas related to the questionnaire format and system-generated instructions and are provided guidance on how to avoid giving conflicting or insufficient information.
Closure Date:
3 We recommended the under secretary for benefits implement a plan to make certain that Veterans Benefits Administration decision makers receive refresher training on identifying and resolving heart disability benefits questionnaires that are insufficient for evaluation purposes and monitor the effectiveness of the training.
Closure Date:
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| 19-08666-212 | Surrogate Decision-Maker, Clinical, and Patient Rights Deficiencies at the Robley Rex VA Medical Center in Louisville, Kentucky | Hotline Healthcare Inspection | ||
1 The Robley Rex VA Medical Center Director ensures staff document clinical assessments of patients’ decision-making capacity throughout hospitalization as required by Veterans Health Administration policy.
Closure Date:
2 The Robley Rex VA Medical Center Director evaluates social worker practices related to facilitating the release of information when a patient lacks decision-making capacity, and takes action as indicated.
Closure Date:
3 The Robley Rex VA Medical Center Director establishes “reasonable inquiry” parameters for determination of a surrogate as required by Veterans Health Administration policy and provides staff education as needed.
Closure Date:
4 The Robley Rex VA Medical Center Director ensures that when patients lack decision-making capacity, staff verify and document the status of surrogates, and the efforts to identify surrogates, according to Veterans Health Administration policy.
Closure Date:
5 The Robley Rex VA Medical Center Director evaluates the quality and comprehensiveness of clinical documentation in support of diagnoses and treatment decisions across the patient’s hospitalization, and takes action as indicated.
Closure Date:
6 The Robley Rex VA Medical Center Director ensures interdisciplinary and cross-service communication and collaboration for complex patients and monitors compliance.
Closure Date:
7 The Robley Rex VA Medical Center Director ensures providers complete medication reconciliation for patients transferred to the mental health unit(s) as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
Closure Date:
8 The Robley Rex VA Medical Center Director ensures compliance regarding completion of documentation of PRN (as needed) medication effectiveness as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
Closure Date:
9 The Robley Rex VA Medical Center Director reviews clinical decision-making and administrative processes relative to the patient’s admission to hospice, and takes appropriate actions as indicated.
Closure Date:
10 The Robley Rex VA Medical Center Director develops a mechanism to ensure involuntary admissions (72-hour holds) for current and future patients are managed and documented according to Veterans Health Administration and Robley Rex VA Medical Center policies, and Kentucky state laws.
Closure Date:
11 The Robley Rex VA Medical Center Director develops a mechanism to ensure that patients in behavioral restraints are assessed every 15 minutes as required, and that documentation complies with Veterans Health Administration policy.
Closure Date:
12 The Robley Rex VA Medical Center Director ensures that its policy on restraints and seclusion is updated to reflect the frequency of training requirements, and that staff are appropriately trained and competent in the use of restraints as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
Closure Date:
13 The Robley Rex VA Medical Center Director takes action to ensure processes for reviewing inpatient deaths is consistent with Veterans Health Administration policy.
Closure Date:
14 The Robley Rex VA Medical Center Director reviews the patient’s continuum of care and evaluates if additional peer reviews and/or other quality reviews are warranted, and takes action as indicated.
Closure Date:
15 The Robley Rex VA Medical Center Director reviews the circumstances related to an unauthorized individual making decisions for the patient and conducts appropriate disclosure to the patient’s representative as warranted.
Closure Date:
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| 20-00068-206 | Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures implementation of specific action items are documented in Quality Council minutes when problems or opportunities for improvement are identified.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum required gastroenterology-specific criteria for focused and ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
5 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures all medical equipment is identified as safe for patient use.
Closure Date:
6 The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that staff remove expired medications from patient care areas.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy to assess adherence to the therapy plan and effectiveness of treatment.
Closure Date:
11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that employees receive initial suicide prevention training within 90 days of hire and annual refresher training thereafter.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that traffic flow in the Gastroenterology clean storage areas is restricted.
Closure Date:
14 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity requirements are maintained and documented for the Gastroenterology clean storage areas.
Closure Date:
15 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff receive competency assessments prior to reprocessing reusable medical equipment.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 19-09776-223 | Alleged Deficiencies in Pharmacy Service Procedures at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Hotline Healthcare Inspection | ||
1 The Louis A. Johnson VA Medical Center Director ensures implementation of a process to document and track orientation, competency assessment, and annual competencies of pharmacy staff, and monitors compliance.
Closure Date:
2 The Louis A. Johnson VA Medical Center Director ensures facility leaders are trained in the process of reporting any and all future diversions and loss incidents according to requirements outlined in VHA Directive 1108.01, Controlled Substance Management, May 1, 2019.
Closure Date:
3 The Louis A. Johnson VA Medical Center Director conducts a review of the circumstances that resulted in the misplacement of testosterone and develops an action plan to prevent a similar recurrence, if warranted.
Closure Date:
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15039