All Reports

The Executive Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete final peer reviews within 120 calendar days or approves a written extension request.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews professional practice evaluations for licensed independent practitioners’ privileging requests and documents the review in meeting minutes.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for reprivileging decisions.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluations completed by practitioners with similar training and privileges.

The Charlie Norwood VA Medical Center Director ensures primary care teams adhere to Veterans Health Administration policies related to mental health screenings, consult management, and care coordination, and monitors compliance.

The Charlie Norwood VA Medical Center Director develops a process to ensure that Emergency Department staff communicate patients’ referral information from the Veterans Crisis Line to Emergency Department providers.

The Charlie Norwood VA Medical Center Director ensures that suicide prevention staff documentation is complete and accurate, and actions are taken to resolve issues identified in Veterans Crisis Line referrals prior to closure.

The West Palm Beach VA Healthcare System Director ensures that pulmonary providers communicate and document test results and surveillance care plans to patients.

The West Palm Beach VA Healthcare System Director ensures that pulmonary providers and staff are trained on the use of return-to-clinic orders and monitors for compliance.

The West Palm Beach VA Healthcare System Director ensures that chiropractor providers review community care notes and takes action as needed.

The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.

The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.

The Veterans Integrated Service Network Director evaluates the role of the Patient Safety/ Risk Management Subcommittee to determine the degree to which the subcommittee will address facility level performance with Patient Safety Program activities and tracking of action plans when a deficiency is identified, and updates the subcommittee charter as warranted.

The Under Secretary for Health evaluates the process for programmatic oversight by VA’s National Center for Patient Safety over Veterans Integrated Service Networks’ and facilities’ patient safety programs.

The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.

The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.

The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.

The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.

The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.

The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.

The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.

The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.

The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.

The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.

The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.

The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis or includes the patient safety event in an aggregate review for all events assigned an actual or potential safety assessment code score of three.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs’ determinations to continue current privileges are based on Ongoing Professional Practice Evaluation activities.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Committee’s decision to recommend continuation of privileges is based on Ongoing Professional Practice Evaluation results.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility surgical work groups consistently review surgical deaths.

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

The Southeast Network Director facilitates a comprehensive review of Patient A’s episode of care, from the time and date of the patient’s hospitalization through the date and time of the patient’s death, to identify practitioner and process improvements that may reduce the potential for future incidents, and takes appropriate actions.