All Reports

The OIG recommends facility leaders relocate papers and folders outside of patient examination rooms or secure them in protective coverings to mitigate the risk of infection.

The OIG recommends the Veterans Integrated Service Network Director takes actions to ensure stable and consistent leadership at the facility.

The OIG also recommends Veterans Integrated Service Network leaders assist facility leaders to improve interactions with local union leaders.

The OIG recommends the Interim Medical Center Director ensures all security cameras are operational.

The OIG recommends the Interim Medical Center Director ensures primary care teams are staffed according to Veterans Health Administration guidelines.

The OIG recommends facility leaders ensure staff understand procedures for cleaning equipment and continue to monitor the physical separation of clean and dirty items in storage spaces.

The OIG recommends that primary care leaders incorporate feedback from primary care staff and include them in process improvement projects.

The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.

The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.

The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for improvement and provided guidance on facilities’ action plans to address the deficiencies.

The OIG recommends that Veterans Integrated Service Network leaders ensure facility staff separate clean and dirty equipment and supplies to prevent cross-contamination.

The OIG recommends Veterans Integrated Service Network leaders ensure facility staff keep the environment clean and safe.

The OIG recommends that executive leaders ensure front desk personnel are competent in communicating with sensory-impaired veterans.

The OIG recommends that facility leaders consistently identify opportunities for improvement, ensure staff implement appropriate action plans, and evaluate actions for sustained improvement.

The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.

The OIG recommends facility leaders confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments.

The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.

The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.

The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.

The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.

The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.

The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.

The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.

The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.

The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.

The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.

The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.

The Richmond VA Medical Center Director ensures completion of a clinical review of patient 2’s cardiothoracic surgical episode of care and takes action as appropriate.

The Under Secretary for Health ensures that consideration to reactivate the heart transplant program at the Richmond VA Medical Center includes a comprehensive analysis of transplant referral volume, leadership competency, and transplant team proficiency.

The Under Secretary for Health ensures that VA Mid-Atlantic Health Care Network and Richmond VA Medical Center leaders conduct a rigorous surveillance of quality measures if the heart transplant program is reactivated and emphasize safely meeting program target volumes to maintain clinical experience.

The Richmond VA Medical Center Director ensures the chief of surgery conducts a review of the cardiothoracic section chief’s unprofessional behaviors and develops a plan to address complaints.

The Richmond VA Medical Center Director ensures surgical leaders review cardiothoracic staff’s concerns and take action to create a culture of safety, and considers the use of resources such as the National Center for Organization Development.

The VA Mid-Atlantic Health Care Network Director develops a process for ensuring VA Mid-Atlantic Health Care Network staff provide timely and complete responses to facility leaders’ requests for clinical care reviews.

The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.

The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.

The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.

The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.

The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.

The VA Augusta Health Care System Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.

The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.

The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.

The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.

The VA Augusta Health Care System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for improvement.

The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.

The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.

The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.

The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.

The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.

The VA Augusta Health Care System Chief of Staff ensures that safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.

The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.

The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.

The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.

The OIG recommends that facility leaders submit a plan to the OIG detailing steps to address snow removal on pathways leading to and from buses during and after snowstorms.

The OIG recommends that facility leaders consider clarifying signage by identifying the services located in each building to help direct veterans.

The OIG recommends that facility leaders implement navigation tools and cues that accommodate visually impaired veterans to help them enter the main doors.

The OIG recommends that facility leaders consider distributing toxic exposure screening information where veterans can easily obtain it when entering the facility.

The OIG recommended the Facility Director work with Veterans Integrated Service Network leaders to reevaluate the current bed level capacity and submit the bed change request as required.

The OIG recommended the Facility Director ensures staff secure the pneumatic tube system to prevent unauthorized access to medications.

The VA Black Hills Health Care System Director ensures that summary suspensions and related privileging actions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

The VA Black Hills Health Care System Director in conjunction with facility leaders and surgical service leaders, ensures a focused clinical care review is completed of the care provided by the subject provider according to Veterans Health Administration policy, and takes action as warranted.

The VA Black Hills Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates the patient safety event reporting processes, identifies deficiencies, and takes action as warranted to ensure compliance with entering adverse events or close calls into the Joint Patient Safety Reporting system.

The VA North Florida/South Georgia Health System Director consults with the Office of General Counsel to ensure system and service line policies and practices related to voluntary and involuntary admissions under the Baker Act provide clear guidance and are consistent with Florida state law as allowed by federal law and Veterans Health Administration regulations.

The VA North Florida/South Georgia Health System Director ensures that providers document their rationales for initiating involuntary examinations under the Baker Act within a patient’s electronic health record and monitors compliance.

The VA North Florida/South Georgia Health System Director verifies that a process is in place to provide patients who are admitted for an involuntary examination under the Baker Act with written information on their rights and monitors compliance.

The VA North Florida/South Georgia Health System Director confirms that mental health staff document offering evidence-based therapies during treatment planning with patients diagnosed with posttraumatic stress disorder, as required by Veterans Health Administration policy, and monitors compliance.

The VA North Florida/South Georgia Health System Director ensures that all licensed mental health staff receive annual training on the Baker Act and tracks compliance.

The VA North Florida/South Georgia Health System Director determines if there is a need for non-mental health providers in the emergency department to complete Baker Act training and takes action as warranted.

The VA North Florida/South Georgia Health System Director, in consultation with Veterans Health Administration’s Senior Security Officer, ensures system police, emergency department, and mental health staff follow VA policy specific to assisting staff in the prevention of patient elopements prior to an involuntary mental health evaluation and tracks compliance.

The VA North Florida/South Georgia Health System Director develops a process to provide oversight of compliance with all elements required by state law for use of the Baker Act as permitted by federal law and Veterans Health Administration policy.

The VA North Florida/South Georgia Health System Director, in consultation with the Office of General Counsel, determines whether Baker Act reporting by the system is required and provides clear guidance for applicable reporting processes.

The VA North Florida/South Georgia Health System Director develops a process to ensure system policies adhere to Veterans Health Administration Directive 0999(1), medical center policy standardized template as it pertains to assignment of oversight responsibilities.

The VA North Florida/South Georgia Health System Director directs a review of current patient advocate processes for follow-up and resolution with complainants, updates the process as warranted, and monitors compliance.

The VA North Florida/South Georgia Health System Director considers having the patient advocate process for tracking and monitoring trends capture complaints specific to involuntary admissions for leaders’ awareness and follow-up.

The VA Eastern Colorado Health Care System Director evaluates and ensures that telemetry medical instrument technicians and registered nurses comply with Veterans Health Administration and facility policy requirements for documentation and scanning, specifically related to telemetry oxygenation and rhythm strips and change in patient condition.

The VA Eastern Colorado Health Care System Director in conjunction with telemetry nursing leaders, ensures completion of a comprehensive review of the telemetry program and documented oversight of compliance with medical instrument technician monitoring expectations, identifies deficiencies, and takes actions as warranted.

The VA Eastern Colorado Health Care System Director promotes and encourages all staff to use the Joint Patient Safety Reporting system to report patient safety events and ensures telemetry staff and managers are trained on the use of the Joint Patient Safety Reporting system.

The VA Eastern Colorado Health Care System Director evaluates and ensures quality and patient safety event review processes comply with Veterans Health Administration guidance, specifically regarding rejection and follow-up of patient safety reports.

The VA Eastern Colorado Health Care System Director and facility leaders meet all Veterans Health Administration requirements for institutional disclosures for events meeting institutional disclosure criteria.

The VA Eastern Colorado Health Care System Director ensures review of facility clinical alarm management and committee processes, identifies deficiencies, and takes actions as warranted.

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System rapid response policy is in alignment with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policies and procedures related to responding to medical emergencies do not conflict.

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.

The Phoenix VA Health Care System Director ensures layperson cardiopulmonary resuscitation training is offered in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.

The Phoenix VA Health Care System Director determines the need for, and implements placement of, public access automated external defibrillators in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation

The Phoenix VA Health Care System Director assesses outpatient clinic compliance with vital sign completion and documentation, identifies deficiencies, and takes action as warranted.

The Phoenix VA Health Care System Director reviews and assesses the need for non-clinical staff training on the use of the Joint Patient Safety Reporting system, and takes action as warranted.

The Phoenix VA Health Care System Director ensures complaints are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.

The Phoenix VA Health Care System Director reviews organizational communication channels and ensures consistency with Veterans Health Administration high reliability organization principles and I CARE values

The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administration’s established time frame, and monitors compliance.

The Under Secretary for Health evaluates the circumstances that led to Veterans Integrated Service Network leaders’ lack of awareness of the 11-month curtailment of cardiothoracic surgeries and takes action as needed to ensure effective Veterans Integrated Service Network oversight of facility clinical operations.

The Veterans Integrated Service Network Director evaluates the circumstances that led to the failure of VA Eastern Colorado Health Care System leaders to submit a proposal request and business plan to resume cardiothoracic surgeries after an 11-month pause to the Veterans Integrated Service Network Director for review and approval and takes action as needed.

The Veterans Integrated Service Network Director ensures facility leaders implement high reliability organization principles to plan for clinical operation changes that include stakeholders, service and section leaders, and staff input.

The Veterans Integrated Service Network Director ensures that the educational needs of the facility’s residents are evaluated and maintained during service and program changes, including on-site supervision, as required by Veterans Health Administration directive.

The VA Eastern Colorado Health Care System Director reviews and finalizes Facility Draft Policy 11-55 titled Call Escalation of Communication and trains attendings, fellows, residents, and staff members on the policy.

The VA Eastern Colorado Health Care System Director reviews root cause analysis requirements for interviewing individuals relevant to root cause analyses and ensures staff are trained accordingly.

The Executive Director ensures staff complete root cause analyses for sentinel events.

The Chief of Staff ensures service chiefs initiate Focused Professional Practice Evaluations for newly appointed licensed independent practitioners.

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures service chiefs consider specialty-specific data during licensed independent practitioners’ Ongoing Professional Practice Evaluations.

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations.

The Chief of Staff ensures the Healthcare Delivery Council or an appropriately identified executive committee of the medical staff reviews professional practice evaluation results.

The Veterans Integrated Service Network Chief Medical Officer oversees the healthcare system’s privileging processes.

The Executive Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms for sleeping rooms in the Acute Psychiatric Unit.

The Executive Director ensures staff test panic alarms in the Acute Psychiatric Unit and document VA police response times.

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures the suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.