All Reports

Death of a Patient, Deficiencies in Domiciliary Safety and Security, and Inadequate Contractual Agreement at the VA Northeast Ohio Healthcare System in Cleveland
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19-07091-159
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The VA Northeast Ohio Healthcare System Director conducts a full review of the patient’s care, including electrocardiograms and methadone initiation, and considers whether an institutional disclosure is warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Northeast Ohio Healthcare System Director ensures that electrocardiograms are completed prior to and during methadone treatment in accordance with Veterans Health Administration Pharmacy Benefits Management Services recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The VA Northeast Ohio Healthcare System Director ensures that domiciliary leaders implement a process to monitor the integrity of Volunteers of America staff documentation including health and safety rounding sheets and additional documentation directly pertaining to patients’ health, safety, and security.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 6/11/2020
The VA Office of Asset Enterprise Management Director ensures that the Residential Services Agreement includes references to the Services Provider Contract between CGA LSVA Residential, LLC and Volunteers of America.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 6/11/2020
The VA Office of Asset Enterprise Management Director, in consultation with the VA Office of General Counsel, determines if the Residential Services Agreement and the new term agreement needs to be reformed, or whether new contracts should be executed that clearly define the rights and responsibilities of all parties with respect to domiciliary services.
Delays in Diagnosis and Treatment and Concerns of Medical Management and Transfer of Patients at the Fayetteville VA Medical Center, North Carolina
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19-08256-124
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures that ordering providers review, acknowledge, and document an action plan for abnormal laboratory results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director considers initiating an institutional disclosure for the failure of primary care provider 1’s clinical action and follow-up for Patient A’s abnormal test results and takes necessary actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2024

The Fayetteville VA Medical Center Director ensures that facility Community Care staff process Community Care consults according to the Veterans Health Administration policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director conducts a comprehensive review of Patient A’s and Patient B’s episode of care and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Fayetteville VA Medical Center Director evaluates the facility’s treating capabilities, delineates the medical conditions appropriate for admission, and updates the Policy for Admission/Discharge/Care of Patients to Intensive Care Unit.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Fayetteville VA Medical Center Director conducts an analysis of the inter-facility transfer process for patients in emergency situations, and develops and implements strategies and actions for improvement.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director updates the Patient Transfer Coordination policy to include the improvements from the transfer process analysis.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director makes certain that facility staff are trained on the updated Patient Transfer Coordination policy and emergency inter-facility transfer process for inpatients and monitors the process, including timeliness of transfers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director reviews Patient B’s emergency medical services’ 911 call cancellation, considers initiating institutional disclosure, and takes appropriate action as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures the Critical Care Committee thoroughly evaluates code blue events, identifies related performance and system issues, makes recommendations, and ensures actions are implemented.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director makes certain that solo practitioners have the privilege-specific competency components of their focused and ongoing professional practice evaluations performed by another provider with similar training and privileges and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures inter-facility patient data is collected, analyzed and incorporated into the facility’s quality management program.
Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center, Augusta, Georgia
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19-08296-118
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director ensures compliance with requirements outlined in Veterans Health Administration and Charlie Norwood VA Medical Center policy memorandums for the prevention and management of pressure injuries, including nursing documentation requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director ensures Critical Care Unit nursing staff receive ongoing training to manage patients at risk for developing pressure injuries.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director evaluates tele-ICU services, and makes changes as needed to ensure cardiac-monitored patients receive safe care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Charlie Norwood VA Medical Center Director ensures that a review to evaluate the circumstances related to Patient 8’s respiratory care is conducted and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director reviews current practices related to sitter availability when a physician orders a 1:1 sitter for Critical Care Unit patients and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director reviews current practices related to Critical Care Unit nursing staff assignments and takes action as indicated to support safe patient care when intravenous medications that require frequent dose adjustments are prescribed.
Radiology Concerns at the VA Illiana Health Care System Danville, Illinois
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18-05350-135
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2021
The Under Secretary for Health adopts the National Radiology Program Office established guidelines and confers with the National Radiology Program Office to develop and incorporate a risk stratification methodology of the random sample of imaging modalities reviewed, to better inform radiologists’ professional practice evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Veterans Integrated Service Network Director provides continued oversight of the National Teleradiology Program expanded review results, ensures an appropriate response from VA Illiana Health Care System, and takes actions, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director verifies that appropriate patient follow-up occurs, disclosures are conducted for events that meet disclosure criteria, and compliance with Veterans Health Administration policy is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director ensures the Radiology Service follows VA Illiana Health Care System policy to develop and implement a quality assurance and performance plan and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director considers following the National Guidelines for Radiology Professional Competency for radiologist competency reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director evaluates the final findings of the National Teleradiology Program review to determine what additional steps are required, including large-scale disclosure and reporting to outside agencies.
Manipulation of Radiology Reports and Leadership Failures in the Medical Imaging Service at Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin
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18-06074-123
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Under Secretary for Health ensures that the planning and implementation of the new electronic health record includes a process for addenda insertion, deletion, and consistent formatting for radiology reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Under Secretary for Health reviews Veterans Health Administration policy related to management of health information in the electronic health record, evaluates the circumstances that led to the Division Manager’s decision to direct the deletion of a completed and verified imaging report, and takes action, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director ensures a review of the radiology report for the patient with conflicting imaging study results and confirms that the most accurate impression is evident in electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2020
The Veterans Integrated Service Network Director reviews access, management, and the Veterans Integrated Service Network oversight of the Clement J. Zablocki VA Medical Center picture archiving and communication system practices, and takes action to remedy issues identified during the review, as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director reviews the oversight and management of the Medical Imaging Service, confers with human resources, makes recommendations for improvement as indicated, and monitors progress.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director completes an evaluation of the Medical Imaging Service’s culture, morale, and team cohesion, develops an action plan for improvement, and monitors progress.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director evaluates the need for Medical Imaging Service staff to receive training on workplace intimidation and the process for employee reporting of concerns, and takes actions, as indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Veterans Integrated Service Network Director makes certain that future hotline case referrals are investigated in accordance with Veterans Affairs policy related to Office of Inspector General Hotline complaint referrals, and provides oversight of facility responses.
Deficiencies in a Cardiac Research Study at the VA St. Louis Health Care System, Missouri
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19-07682-103
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2021
The VA St. Louis Health Care System Director makes certain the Chief of Staff ensures research providers take action based on stress-test results to include coordination of care and notification to primary providers as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The VA St. Louis Health Care System Director ensures that a full retrospective review of patients enrolled, to date, in the Arm Exercise Versus Pharmacologic Stress Testing for Clinical Outcome Prediction study with positive stress tests received communication of their test result and follow-up care if indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The VA St. Louis Health Care System Director ensures that a review of Patient A’s case is completed to determine if disclosure is warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2021
The VA St. Louis Health Care System Director makes certain that the Institutional Review Board ensures adherence to the research study plan related to communication to the primary provider of patient enrollment in the study.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The VA St. Louis Health Care System Director ensures alignment of content for the regadenoson stress test protocols and education provided to staff and healthcare trainees.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The VA St. Louis Health Care System Director ensures the stress test laboratory regadenoson protocol meets VA St. Louis Health Care System Memorandum 00-34 requirements.
Deficient Staffing and Competencies in Sterile Processing Services at the VA Black Hills Healthcare System, Fort Meade Campus, South Dakota
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19-07096-108
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Topics:  Patient Safety ● Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2020
The VA Black Hills Healthcare System Director complies with Veterans Health Administration requirements that Level 1 and 2 facilities have an assistant chief of Sterile Processing Services on staff.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Black Hills Healthcare System Director ensures that Sterile Processing Services leaders track changes to manufacturer’s instructions, updates standard operating procedures, retrains staff as needed, and monitors compliance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2020
The VA Black Hills Healthcare System Director ensures that Sterile Processing Services leaders maintain up-to-date staff competencies for reprocessing, and monitors compliance with Veterans Health Administration policy.
Quality of Care Issues in the Community Living Center and Emergency Department at the Dayton VA Medical Center, Ohio
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18-01275-89
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director identifies facility resources and other means for provider education and training to strengthen skills when deficiencies in care are identified during peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures that Peer Review Committee meeting minutes document reasons for changes to peer review levels, and that changes are consistent with its review of relevant aspects of clinical care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures review of procedures to make certain gastroenterology staff coordinate care with referring providers and provide staff training on care coordination procedures as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2021
The Dayton VA Medical Center Director makes certain that Community Living Center staff utilize the Situation, Background, Assessment, and Recommendation communication tool and document transfers to the Emergency Department in accordance with Dayton VA Medical Center policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director considers consolidating Medical Center policies related to patient transfers and transports to and from the Emergency Department into one policy to provide clear guidance to staff to effect timely transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures consistent implementation of standing orders in the Emergency Department.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The Dayton VA Medical Center Director verifies policies and procedures are in place for monitoring of critically ill patients to track deterioration and need for intervention in the Emergency Department and during transport, and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2021
The Dayton VA Medical Center Director ensures that handoff communication between Emergency Department providers is accurate and documented in the electronic health record during transitions in care in accordance with Dayton VA Medical Center policy, and compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures review of results from the revision of the Dayton VA Medical Center policy on threshold for peer review findings to trigger management reviews in order to confirm the revised policy is appropriately sensitive to identify provider practice issues that constitute patient safety concerns, and revise the policy if needed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director confirms all code carts in the Emergency Department are processed and secured consistent with Dayton VA Medical Center policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2021
The Dayton VA Medical Center Director ensures Emergency Department supplies are secured and maintained consistent with Dayton VA Medical Center policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Dayton VA Medical Center Director ensures continued monitoring and compliance with bar code medication administration policy in the Community Living Center.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2021
The Dayton VA Medical Center Director reviews document management procedures for professional practice evaluations and takes actions as needed to comply with the VA Records Control Schedule.
Concern Regarding a Patient Death and Alleged Conflicts of Interest at the VA Western Colorado Health Care System, Grand Junction
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19-06435-84
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2020
The VA Western Colorado Health Care System Director ensures the VA Western Colorado Health Care System Chief of Staff evaluate the management of the identified patient’s abnormal test results and provide re education to all primary care providers on their duties when alerted to abnormal blood smear results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2020
The VA Western Colorado Health Care System Director requests a conflict of interest review from the VA Office of General Counsel regarding the urologists’ ownership of the extracorporeal shock wave lithotripsy company and provides an accurate description of the alternate forms of treatment and the comparable costs associated with those treatments.
Comprehensive Healthcare Inspection of the Alaska VA Healthcare System, Anchorage, Alaska
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19-00054-72
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2020
The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors the patient safety manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The facility director ensures that a formal process is established to review override reports and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The chief of staff verifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2020
The chief of staff ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The facility director confirms that the Women’s Health Committee is comprised of the required core members and monitors committee’s compliance.
Deficiencies in the Women Veterans Health Program and Other Quality Management Concerns at the North Texas VA Healthcare System
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19-06378-73
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Topics:  Patient Safety ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure sufficient staffing to provide gender-specific care by designated women’s health primary care providers.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director ensures steps are taken to reduce panel sizes of designated women’s health primary care providers as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The VA North Texas Health Care System Director reviews the Veterans Health Administration policy recommended extended appointment times for comprehensive women veterans healthcare examinations and takes action as appropriate to achieve compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure that appropriate resources, such as equipment, supplies, and space, are adequate to support comprehensive women veterans healthcare.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The VA North Texas Health Care System Director takes steps to ensure that the Women Veterans Program Manager participates in the environment of care rounds and monitors for compliance with Veterans Health Administration policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director evaluates clinic areas where gender specific primary care is currently provided and when planning renovations to existing areas to ensure adequate restroom access for women veterans and takes action as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The VA North Texas Health Care System Director continues to evaluate and support staffing changes in the gynecology specialty clinic to enhance services.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The VA North Texas Health Care System Director ensures implementation of an effective tracking mechanism to ensure VA providers receive results for women veterans referred to care in the community and monitors for compliance with Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The VA North Texas Health Care System Director verifies review of the electronic health records of women veterans referred to Care in the Community whose medical records have not been obtained and takes action if indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure performance and evaluation processes provide the intended assessment of compliance with Veterans Health Administration requirements and monitors for compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director verifies that institutional disclosures are conducted for events that meet disclosure criteria and monitors for compliance with Veterans Health Administration policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure the required number of combined totals of root cause analyses and aggregated reviews are completed, and monitors for compliance with Veterans Health Administration policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director ensures completion of root cause analyses within the required timeframes and monitors for compliance with Veterans Health Administration policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The VA North Texas Health Care System Director verifies that staff complete training on policy related to high-risk patient goals of care conversations for life-sustaining treatment plans and monitors for completion of training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The VA North Texas Health Care System Director ensures staff conduct high-risk patient goals of care conversations for life-sustaining treatment plans as required and monitors for compliance with Veterans Health Administration policy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The VA North Texas Health Care System Director takes steps to ensure provider documentation of high-risk patient goals of care and life-sustaining treatment plan in the required electronic health record template and monitors for compliance with Veterans Health Administration policy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The VA North Texas Health Care System Director verifies capture and reporting of all codes to the resuscitation subcommittee and monitors for compliance with Veterans Health Administration policy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The VA North Texas Health Care System Director ensures that the Critical Care Committee minutes reflect corrective action plans and follow-through to remediate concerns identified by the resuscitation subcommittee and monitors for compliance.
A Delay in Patient Notification of Test Results and Other Communication Issues at the Bath VA Medical Center, New York
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19-07070-75
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The Bath VA Medical Center Director ensures that surrogate providers comply with the facility’s notification policy when providing coverage.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The Bath VA Medical Center Director ensures that the Bath VA Medical Center Patient Transfer Policy clearly defines a process for outpatient transfers to a higher level of care utilizing facility paramedics.
Comprehensive Healthcare Inspection of the West Texas VA Health Care System, Big Spring, Texas
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19-00034-62
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2020
The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director ensures that facility leaders review a Patient Safety Annual Report at the end of the fiscal year and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff ensures that the Code Blue/Rapid Response Team Committee reviews each resuscitative episode and monitors committee compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2020
The facility director ensures that the controlled substance coordinator provides the monthly summary of findings and quarterly trends report to the director and monitors the controlled substance coordinator’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the Quality Executive Board reviews the controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the controlled substances coordinator performs and documents competency assessments of the controlled substance inspectors annually and monitors controlled substances coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The facility director makes certain the controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors the inspectors’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2020
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2021
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The facility director confirms that the Women Veterans’ Advisory Committee is comprised of the required core members and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The facility director ensures that urgent care center patients are assigned the appropriate stop codes to capture correct patient workload, productivity, and level of service and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The chief of staff ensures that a written provider staffing contingency plan and backup call schedule are maintained for urgent care center providers and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The facility director confirms that the urgent care center implements the Emergency Department Integration Software tracking program and transmits data to the Emergency Medicine Management Tool and monitors compliance.
Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
|
19-00012-51
|
Topics:  Patient Safety ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The chief of staff ensures the Executive Committee of the Medical Staff reviews quarterly Peer Review Committee summary reports with trends and analysis of aggregate data and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The facility director makes sure the patient safety manager includes a review of relevant literature in the root cause analysis and monitors the patient safety manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director confirms that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The facility director ensures that clinical managers implement corrective actions and monitor for effectiveness when problems or opportunities for improvement are identified and monitors the clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief of staff confirms that clinical service chiefs clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause that do not restrict the providers’ ability to practice independently for more than 30 days with providers and monitors the clinical service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The associate director assures managers remove damaged wheelchairs from service and send them for repair or replacement and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the facility quality manager ensures the Clinical and Performance Board reviews the monthly and quarterly controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses of controlled substances and monitors inspectors’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director ensures that a pharmacist reviews the Omnicell® override report for appropriateness and frequency as required and monitors the pharmacist’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
|
19-00043-66
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The facility director makes certain that required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The facility director ensures that the patient safety manager completes the minimum requirement of eight root cause analyses each year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The facility director ensures that the patient safety manager submits each root cause analysis to the National Center for Patient Safety within the required time frame and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The chief of staff ensures that service chiefs clearly define and communicate focused professional practice evaluation criteria in advance with providers and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The chief of staff ensures that ongoing professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The chief of staff ensures that service chiefs clearly define, share, and document in advance the expectations and outcomes for time-limited focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2021
The associate director ensures that floors and ceilings tiles are repaired, cleaned, and maintained and window screens are replaced and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The associate director ensures expired medical supplies are removed from supply rooms and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The associate director ensures that VA police test panic alarms and evidence of testing is documented and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The facility director ensures that the comprehensive emergency management plan and its required elements are reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2021
The facility director ensures an emergency operations plan is developed and reviewed annually.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff makes certain that clinicians justify and document the reason for initiating the medication and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff ensures that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff ensures clinicians review and reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The facility director requests the required waiver for urgent care clinic operations 24 hours a day, 7 days a week and continues such operations only if the waiver is approved.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The facility director makes certain that a medical director for the urgent care center is formally appointed.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures the urgent care center has a minimum of two registered nurses on staff during all hours of operation and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The chief of staff ensures that appropriate support services are in place during all hours of UCC operation and monitors compliance.
Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
|
19-00038-63
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The chief of staff ensures that peer reviewers consistently use at least one of the aspects of care when conducting peer reviews and monitors reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The chief of staff ensures that managers consistently implement, and document completion of improvement actions recommended by the Peer Review Committee and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The chief of staff ensures that peer review data is reported quarterly to the Executive Committee of the Medical Staff and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures utilization management staff complete and document acute inpatient and observations stay reviews as required and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The facility director ensures that Physician Utilization Management Advisor(s) consistently complete reviews and document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that the patient safety manager or designee completes the required number of root cause analyses that include the required content annually and monitors the patient safety manager’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that the patient safety manager or designee provides an annual patient safety report to facility leaders and monitors the patient safety manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that clinical managers clearly define the criteria, time frames, and expectations with providers in advance for focused professional practice evaluations and monitors the clinical managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff makes certain that the Executive Committee of the Medical Staff reviews and evaluates the focused and ongoing professional practice evaluation results and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The associate director ensures that patients areas are clean and that action is taken to minimize or eliminate identified safety risks in the environment and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director ensures that controlled substances inspectors are appointed in writing with a term not to exceed three years and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that monthly reconciliation of one day’s dispensing from pharmacy to every automated dispensing cabinet and one day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that controlled substances inspectors verify there is evidence of a written or electronic controlled substances order for five randomly selected dispensing activities during monthly inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff confirms that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2022
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided, and monitors clinicians’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures clinicians complete and document medication reconciliation as required and monitors the clinicians’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2021
The facility director confirms that the Women Veterans Health Committee meets at least quarterly, includes required core members, and reports to the appropriate executive committee and monitors the committee’s compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The chief of staff ensures tracking and monitoring of cervical cancer data and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain that the facility has an approved waiver from the national director of Emergency Medicine if the urgent care center continues to operate 24 hours a day, seven days a week.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that the urgent care center is staffed with at least two registered nurses physically present during all hours of operation and monitors compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain that social work services are available to the urgent care center during all hours of operation, and monitors compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that action plans are developed and implemented for underperforming patient flow metrics in the urgent care center and monitors compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The facility director makes certain that appropriate signage is in place to direct patients to the urgent care center and monitors compliance.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that at least one room is identified as the psychiatric intervention room in the urgent care center and monitors compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.
Review of Staffing and Access Concerns at the Mann-Grandstaff VA Medical Center Spokane, Washington
|
19-09017-64
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Mann-Grandstaff VA Medical Center Director takes action to ensure that patients have timely access to care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Mann-Grandstaff VA Medical Center Director ensures continued implementation of corrective actions in response to deficient areas identified in the National Program Office for Sterile Processing report.
Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota
|
19-00468-67
|
Topics:  Suicide Prevention ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that Emergency Department staff notify the facility Suicide Prevention Coordinator when a patient presents with suicidal ideation, as required by the Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care, including consults, and considers whether an institutional disclosure is warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that inpatient consult results are acted upon by the responsible provider or appropriate designee and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director strengthens processes in root cause analyses consistent with Veterans Health Administration requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Under Secretary for Health ensures that the Veterans Health Administration establishes written guidance for root cause analysis teams to identify lessons learned and expectations regarding related actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that the Patient Safety Committee and Quality Management Council meeting minutes include deliberations and tracking of actions to resolution, as required by Veterans Health Administration and facility policy.
Comprehensive Healthcare Inspection of the VA Western New York Healthcare System, Buffalo, New York
|
18-04666-55
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff confirms that all team members responding to resuscitation events have basic or advanced cardiac life support certification and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The chief of staff ensures that service chiefs include required gastroenterology and pathology specific criteria for those specialties in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The chief of staff ensures that the Executive Committee of the Medical Staff reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director makes certain mental health seclusion room floors are cushioned.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures the required inventory of assets and resources is created and reviewed annually by the Emergency Management Committee and approved by executive leaders and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director ensures that staff who conduct monthly review of balance adjustments not be the same staff that perform and document the balance adjustments and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that controlled substances coordinators maintain necessary records and controlled substance inspectors conduct monthly physical inventory of the controlled substances storage area that are completed on the day initiated and monitors controlled substance coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that the pharmacy staff complete the pharmacy inventory checks as required and monitors staff compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director confirms that the facility has a full-time women veterans program manager and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that the Women Veterans Health Committee meets quarterly, is comprised of required core members, reports to executive quadrad leadership with signed minutes, and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The facility director makes certain that the emergency department has a licensed physician privileged to staff the department during all hours of operation and monitors the department’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain the emergency department has the necessary resources readily available to treat sexual assault patients and monitors compliance.
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