All Reports

Comprehensive Healthcare Inspection of the VA Puget Sound Health Care System in Seattle, Washington
|
20-01261-194
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines the reasons for noncompliance and ensures that improvement actions recommended by the Executive Leadership Council are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee completes at least eight patient safety analysis processes each fiscal year.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee includes an analysis of underlying systems in all root cause analyses.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that improvement actions identified from root cause analyses are implemented.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines reasons for noncompliance and ensures the Patient Safety Manager or designee provides an annual patient safety report to healthcare system leaders.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document focused professional practice evaluation criteria in practitioner profiles.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that licensed independent practitioners’ professional practice evaluations are completed by providers with similar training and privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that service chiefs’ reprivileging decisions are based on ongoing professional practice evaluation data.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Credentialing and Privileging Committee meeting minutes consistently reflect the review of professional practice evaluation results and the rationale for privileging recommendations.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing for patients prior to initiating long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up evaluations of patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and effectiveness of the interventions.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete goals of care conversations and life-sustaining treatment decisions progress notes.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains the required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete competency assessments.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees receive monthly continuing education.
Audiology Leaders’ Deficiencies Responding to Poor Care and Monitoring Performance at the Eastern Oklahoma VA Health Care System in Muskogee
|
20-04341-182
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director confirms the Chief of Staff, the Service Chief, and the Supervisory Audiologist have processes in place to ensure patients affected by the audiologist’s poor care are identified and receive clinically-indicated follow-up.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s adverse event disclosure requirements, and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2023
The Eastern Oklahoma VA Health Care System Director requires the Chief of Staff, the Service Chief, and the Supervisory Audiologist to complete clinical disclosures, as appropriate, for patients identified as being affected by the audiologist’s poor care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates the process to determine whether a large scale disclosure is required, in accordance with the Veterans Health Administration policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s patient safety reporting requirements, and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The Eastern Oklahoma VA Health Care System Director directs the Chief of Staff, the Service Chief, and the Supervisory Audiologist to notify the Patient Safety Manager of adverse events identified through the review of patients impacted by the audiologist’s poor care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures the Supervisory Audiologist verifies and documents annual competency assessments for audiologists in compliance with facility policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures that the Supervisory Audiologist conducts performance appraisals of audiologists in compliance with the Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with Veterans Health Administration’s state licensing board reporting policy, and takes action as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates a review of the audiologist’s conduct to determine whether a report to the state licensing board is indicated, in accordance with the Veterans Health Administration policy.
Deficiencies in the Mental Health Care of a Patient who Died by Suicide and Failure to Complete an Institutional Disclosure, VA Southern Nevada Healthcare System in Las Vegas
|
20-02993-181
|
Topics:  Mental Health ● Suicide Prevention ● Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures completion of suicide risk screening and evaluation in accordance with Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff collaboratively develop and update safety plans with patients to reflect the patient’s current risk and protective factors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures adherence to Veterans Health Administration requirements and VA Southern Nevada Healthcare System Standard Operating Procedure 116-14, Suicide Prevention Daily Operations, October 2019, in the consideration of high risk for suicide patient record flags.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director evaluates substance use disorder diagnostic and treatment referral processes for patients on the Inpatient Mental Health Unit and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director reviews current practices to ensure Inpatient Mental Health Unit staff reconcile and incorporate critical clinical information into treatment and discharge planning.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director expedites the establishment of mental health treatment coordinator policy in accordance with Veterans Health Administration requirements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff coordinate discharge plans with outpatient treatment providers, in accordance with Veterans Health Administration requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures patient complaints and requests are addressed in accordance with Veterans Health Administration requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director promotes leaders’ accurate identification of sentinel events consistent with The Joint Commission definition and Veterans Health Administration requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director conducts a full review of the patient’s care, determines whether an institutional disclosure is warranted, and takes action as indicated.
Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon
|
20-01257-180
|
Topics:  Patient Safety ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety and Value Council’s recommended improvement actions are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Utilization Management Committee’s recommended improvement actions are fully implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures all root cause analysis actions are fully implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
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 aberrant drug-related behaviors prior to initiating long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct follow-up assessments that include adherence to the pain management plan of care and effectiveness of the interventions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete life-sustaining treatment decisions progress notes prior to hospice referrals.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Women Veterans Health Committee meetings.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures standard operating procedures are kept up-to-date and reviewed at least every three years.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Endoscopy Clinic clean storage room maintains the required relative humidity range.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque
|
20-00716-177
|
Topics:  Community Care ● Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2021
The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
Failure of a Primary Care Provider to Complete Electronic Health Record Documentation and Inadequate Oversight at the Charlie Norwood VA Medical Center in Augusta, Georgia
|
20-00354-178
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2021
The Charlie Norwood VA Medical Center Director confirms that the Chief of the Health Information Management program monitors documentation to include patient care episodes without an associated progress note as part of the ongoing electronic health record review process, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The Charlie Norwood VA Medical Center Director ensures a policy defines the required time frame for providers to respond to view alerts.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2021
The Charlie Norwood VA Medical Center Director continues to monitor providers’ compliance with responding to view alerts, evaluates the effectiveness of the implemented strategies to reduce unnecessary view alerts, and assesses the need for retrospective reviews of patient care related to accumulated view alerts.
Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic
|
19-09808-171
|
Topics:  Mental Health ● Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2022
The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Improper Feeding of a Community Living Center Patient Who Died and Inadequate Review of the Patient’s Care, VA New York Harbor Healthcare System in Queens
|
20-02968-170
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director reviews the process of evaluating the Community Living Center nursing staff’s competency for resident feeding and validates their ability to safely feed residents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director ensures that Community Living Center nursing staff are trained on documentation requirements related to feeding of residents and verifies compliance with requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director evaluates documentation of resident feeding, including identifying the staff member who feeds a resident, and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director verifies that a comprehensive review of the patient’s care and death is completed, and evaluates the usefulness of including the pictures and video of the chicken in the review, and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director ensures the Cardiopulmonary Resuscitative Committee evaluates identified issues and makes recommendations for improvement, confirms actions are implemented, and assesses the effectiveness of actions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director verifies staff are aware of what constitutes an adverse event and the requirements to submit incident reports when witnessing or becoming aware of an adverse event.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director evaluates the circumstances surrounding the patient’s death to determine if an institutional disclosure is warranted
Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida
|
20-03535-146
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.
Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
|
18-02496-157
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2023
The Under Secretary for Health ensures that the Veterans Health Administration competency process for locum tenens, newly hired specialty care providers, and newly hired service chiefs is evaluated to confirm that the results of the assessment accurately reflects the clinical competency of providers who are privileged, and takes action, as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health reviews current Veterans Health Administration credentialing and privileging policies to assess guidance related to service chiefs’ ongoing professional practice evaluation and takes action, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health reviews Veterans Health Administration policies to ensure that if facility leaders elect to incorporate pathology 10 percent peer reviews into the performance evaluations of a Pathology and Laboratory Medicine Service Chief, those reviews are performed by a peer without a conflict of interest and takes action, as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2022
The Under Secretary for Health evaluates the use and methodology of the Pathology and Laboratory Medicine Service 10 percent peer review for effectiveness as a quality management tool, and takes action, as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration guidance related to amended pathology reports’ terminology, use, and entry of such reports into patients’ electronic health records, and revises guidance, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health confirms that provisions are included in the Veterans Health Administration record modernization program that ensure amended pathology report alerts are directed to designated facility staff and leaders.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration quality management processes related to external, non-VHA pathology consultant assessments and ensures that facility leaders, the specialty care provider, and requesting providers are notified of the results of such reviews and a tracking process is in place.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Under Secretary for Health confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, & Preparedness to determine whether administrative action is warranted for Veterans Health Administration leaders who did not adequately perform their duties with respect to the issues within this report, and takes action, as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2023
The Under Secretary for Health explores the development of a mandatory alcohol testing policy for individuals including healthcare workers who perform functions that would put patients at risk should the employee work while impaired.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Under Secretary for Health evaluates Veterans Health Administration’s guidance related to impaired healthcare workers and ensures that it addresses the circumstances under which alcohol and or drug testing may be performed; the extent of a retrospective review of care if one is indicated; and the availability of advisors who are knowledgeable on the management of an impaired provider, and takes action, as indicated.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director verifies that peer references obtained during the reappraisal and reprivileging processes are in alignment with VHA Handbook 1100.19, Credentialing and Privileging.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director evaluates the psychological safety climate to ensure facility staff, patients, and the general public are empowered to report concerns and unsafe patient care without fear of reprisal and takes action, as needed.
Comprehensive Healthcare Inspection of the Chillicothe VA Medical Center in Ohio
|
20-01268-143
|
Topics:  Suicide Prevention ● Patient Safety ● Medical Staff Privileging Credentialing

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analysis is reviewed quarterly by the Medical Staff Executive Council.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager monitors implemented root cause analysis action items for sustained improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff determines the reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare professional’s first- or second-line supervisor correctly completes and signs an exit review form within seven business days of the professional’s departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Opioid Safety Review Board monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete suicide prevention training as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required Women Veterans Health Committee members are assigned and consistently attend meetings, and that the committee reports to the Medical Staff Executive Council.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures standard operating procedures are current, align with manufacturers’ guidelines/instructions for use, and are reviewed at least every three years or when there is a change.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that all Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employee competency assessments align with medical center standard operating procedures.
Drug Interactions Related to a Patient Death, Marion VA Medical Center in Illinois
|
20-03380-136
|
Topics:  Mental Health ● Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2022
The Marion VA Medical Center Director ensures that behavioral health staff provide, and document patient education including discussion of side effects and possible adverse drug-drug interactions during telephone encounters when medications are added or adjusted and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2022
The Marion VA Medical Center Director confirms that behavioral health providers are communicating test results to patients and providing necessary clinical interventions as required by policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Marion VA Medical Center Director monitors implementation of Phase Four of the Psychotropic Drug Safety Initiative.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Marion VA Medical Center Director ensures that primary care providers enter return-to-clinic orders and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2022
The Marion VA Medical Center Director verifies primary care and behavioral health staff document contacts, attempted contacts, and letters sent when patients missed their appointments and monitors compliance.
Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in Ohio
|
20-01276-131
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, and Value Committee fully implements and monitors improvement actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that all applicable deaths are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2022
The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria for focused professional practice evaluations in practitioner profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs document the results of focused professional practice evaluations in practitioner profiles.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs collect service-specific ongoing professional practice evaluation data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs recommend continuation of privileges based on ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend initiation and continuation of privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the medical center.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinicians complete suicide prevention safety plans in the expected time frame for patients with High Risk for Suicide Patient Record Flags.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or plans for leave coverage if there is only one designated provider.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Advisory Committee meetings.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturer’s instructions for use.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that CensiTrac® is fully operational.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services maintains written records of weekly eyewash station function testing.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment receive monthly continuing education.
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma
|
20-03886-141
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
The Oklahoma City VA Health Care System Director ensures a review of the clinic note for the patient who experienced temporary loss of vision and confirms that the level of supervision provided by the attending ophthalmologist is accurately reflected in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2021
The Oklahoma City VA Health Care System Director conducts a review to ensure that language used to document resident supervision accurately reflects the presence of the attending ophthalmologist and the degree of resident oversight provided and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Oklahoma City VA Health Care System Director confirms that ophthalmology service procedures include a hand-off process to address attending coverage in situations when an attending ophthalmologist is unavailable to provide timely resident supervision.
Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia
|
20-03593-140
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Under Secretary for Health ensures actions are taken to clarify and broadly disseminate adjudicator expectations for follow-up of an unreturned INV Form 41.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Louis A. Johnson Medical Center Director ensures Pharmacy Service utilizes the required Veterans Health Information Systems and Technology Architecture Automatic Replenishment System to record medication usage data and maintain the records for inventory accountability.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Veterans Integrated Service Network 5 Director conducts management reviews of the care of patients 1–10 as discussed in this report and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director reviews the availability and timeliness of endocrinology consults, and takes any corrective action needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Veterans Integrated Service Network 5 Director ensures evaluation of quality of care concerns or other irregularities (beyond hypoglycemia) of: cases provided by the OIG; cases that may otherwise be pertinent or concerning; and cases brought forward by patients and/or family members who express concerns or make other inquiries about care they received from Ms. Mays. As determined by the VISN, clinical experts external to the facility should be utilized when appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director develops and disseminates guidance on clinical communication(s) to ensure that patient care and outcomes are routinely discussed in appropriate forums, such as interdisciplinary team meetings, and the discussions are documented.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures that close observation documentation is readily available in the electronic health record, and monitors for compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures clinical documentation reviews are completed timely for patient safety and continuity of care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director evaluates the factors and processes surrounding employees’ failures to report and follow up on the unexplained hypoglycemic events, and takes action to ensure appropriate reporting of actual or potential patient safety events, system vulnerabilities, or other unexpected events that offer opportunities for lessons learned.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson Medical Center Director requires that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures that the interdisciplinary mortality review workgroup meet as required with appropriate reporting through oversight council(s), and monitors for compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson Medical Center Director ensures that oversight and reporting practices align with Louis A. Johnson Medical Center policy requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Under Secretary for Health determines the potential advantage of a rescue medication flagging system as an additional tool to evaluate unexplained adverse patient events, including but not limited to mortalities, and takes action as indicated.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director takes action to prioritize and continue efforts to promote a strong culture of safety, such as periodic facility-wide refresher patient safety training or additional patient safety stand downs when indicated, and monitors for effectiveness.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The Under Secretary for Health reevaluates how the Veterans Health Administration collects, reviews, and analyzes mortality data from VA facilities, and takes action to address identified gaps and weaknesses, as indicated.
Deficiencies in Leaders’ Responses to Lapses in Reusable Medical Equipment Reprocessing at the Chillicothe VA Medical Center in Ohio
|
20-02265-100
|
Topics:  Patient Safety ● Supplies and Equipment

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chillicothe VA Medical Center Director develops an oversight plan to address concerns regarding the employee’s compliance with Sterile Processing Services’ procedures as identified by facility and Veterans Integrated Services Network leaders and the Clinical Episode Review Team and confirms effective resolution.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2021
The Under Secretary for Health ensures that the Clinical Episode Review Team reviews the OIG-provided biomedical equipment manufacturer’s information for the automated endoscope reprocessor to determine if the information alters their determination regarding the potential risk to patients or the need for a large-scale disclosure and takes action as necessary.
Deficiencies in Community Living Center Practices and the Death of a Patient Following Elopement from the Chillicothe VA Medical Center in Ohio
|
20-01523-102
|
Topics:  Mental Health ● Patient Safety ● VA Police

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Veterans Integrated Service Network Director consults with the VA Office of Mental Health and Suicide Prevention to review the classification and commitment of patients to the long-stay mental health recovery unit in the facility’s community living center, and makes recommendations to ensure the provision of safe mental health care to patients at the Chillicothe VA Medical Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s calendar year 2019 mental health care, including psychiatric care and medication management, and makes recommendations to the facility, if indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chillicothe VA Medical Center Director establishes a review process to ensure that community living center assessments clearly align the service offerings of the community living center with the individual needs of patients.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chillicothe VA Medical Center Director ensures development of a process to address the care needs of patients who are determined inappropriate for community living center admission.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2021
The Chillicothe VA Medical Center Director establishes a review process to ensure that community living center care plans are consistent with applicable Veterans Health Administration policy and communicated to the community living center staff caring for patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director ensures all community living center long-stay mental health recovery unit staff receive mental health training and pass competency evaluations to provide care specific to the needs of the population served.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director ensures that all facility staff are trained on, and comply with, the facility policy concerning patient behavior management.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2022
The Chillicothe VA Medical Center Director ensures that all facility community living center staff report near-miss and actual missing patient events to patient safety staff and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2021
The Chillicothe VA Medical Center Director ensures that patient safety staff review reported events for patterns or trends indicating risks to patients with a need for mitigation and confirms that effective mitigation strategies are initiated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chillicothe VA Medical Center Director ensures all facility community living center staff receive initial orientation on how to prevent and respond to missing patient events, activating all alerts and involving all relevant staff, as required.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director reviews the facility’s policy on missing patients, ensures that it clearly outlines actions staff should take to prevent missing patient events, and verifies that relevant staff are trained and knowledgeable about such actions.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director ensures that VA police officers receive training and resources to provide missing patient alerts to all facility staff and appropriate law enforcement agencies.
Quality of Colonoscopies in Multispecialty Community-Based Outpatient Clinics
|
20-01386-107
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Under Secretary for Health clarifies requirements for colonoscopy quality indicators for professional practice evaluation and ensures a process is in place to monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2023
The Under Secretary for Health strengthens requirements for colonoscopy quality assurance monitoring that includes analysis of quality indicators to identify trends and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2022
The Under Secretary for Health, in conjunction with the National Gastroenterology Program Director, evaluates implementation of standardized endoscopy software across Veterans Health Administration facilities where colonoscopies are performed and takes action as indicated.
View Alert Process Failures and the Impact on Patient Care at the Central Alabama Veterans Health Care System in Montgomery
|
20-00427-92
|
Topics:  Patient Safety ● Community Care

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health maintains consistent acting or interim leaders and expedites hiring of permanent leaders at the Central Alabama Veterans Health Care System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The VA Southeast Network Director ensures continued collaboration with the Central Alabama Veterans Health Care System to facilitate compliance with guidelines related to view alert management and monitors for ongoing efficiency and sustainability.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director will continue to evaluate and assess the Central Alabama Veterans Health Care System’s view alert management process, effectiveness of its action plan, and modify as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The Central Alabama Veterans Health Care System Director ensures that initial and ongoing provider training and support for the clinical management of view alerts is provided, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director issues guidance and ensures providers are trained on a clearly defined process for the designation of surrogates and the associated responsibilities, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director evaluates the two cases discussed in this report to determine if an institutional disclosure or formal quality management review is needed and takes action accordingly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on the unmanaged abnormal laboratory test and imaging results to include those that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on unscheduled community care consults that were discontinued after 90 days that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director ensures the development and implementation of a policy to address the communication of all test results to ordering providers, or designee, and to patients as required by Veterans Health Administration policy, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director ensures that audits of abnormal laboratory and imaging test results, and unscheduled community care consults that were discontinued after 90 days, are completed to verify providers have managed the associated view alerts, and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director ensures that pending actions are completed for the 33 patient cases with clinical issues referred to the system by the Office of the Inspector General.
Colonoscope Reprocessing at Multispecialty Community-Based Outpatient Clinics
|
20-01387-89
|
Topics:  Patient Safety ● Supplies and Equipment

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2022
The Under Secretary for Health requires facility directors ensure that staff who reprocess colonoscopes at community-based outpatient clinics complete initial training within the required 90 days prior to independently reprocessing equipment and maintain documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2022
The Under Secretary for Health requires facility directors confirm that sterile processing services staff who reprocess colonoscopes at community-based outpatient clinics receive ongoing continuing education through monthly in-services and maintain documentation.
Displaying 201 - 220 of 267