All Reports

Comprehensive Healthcare Inspection of the El Paso VA Health Care System in Texas
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22-00043-39
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Topics:  Medical Staff Privileging Credentialing ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2024

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.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2023
The Chief of Staff determines the reasons for noncompliance and ensures that practitioners with similar training and privileges complete Focused Professional Practice Evaluations of licensed independent practitioners.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Clinical Executive Board reviews and recommends licensed independent practitioners for reprivileging based on individual practitioners’ Ongoing Professional Practice Evaluations and documents its decisions in meeting minutes.
Comprehensive Healthcare Inspection of the Lexington VA Health Care System in Kentucky
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21-03308-24
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Topics:  Medical Staff Privileging Credentialing ● Patient Safety ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2024

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

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2024

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.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2024

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.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2025

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.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures staff have a current local intranasal naloxone policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2022
The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain managers adhere to commercial product expiration dates in the community living center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2023
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures managers keep furnishings safe and in good repair.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2022
The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff develop abatement plans to minimize risks for suicide and suicide attempts in acute inpatient mental health units.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete 100 percent of required universal and setting-specific screenings and Comprehensive Suicide Risk Evaluations.
Comprehensive Healthcare Inspection of the Louisville VA Medical Center in Kentucky
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21-03309-23
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Topics:  Medical Staff Privileging Credentialing ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures governing committees report to the Executive Leadership Council.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently use at least one of the nine aspects of care when conducting peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers implement improvement actions recommended by the Peer Review Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations within clearly defined time frames.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2023
The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.
Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2021
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22-00818-03
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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: 5/25/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility peer review committees recommend improvement actions for Level 3 peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2025

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility surgical work groups meet monthly and core members consistently attend meetings.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2023

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.

Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance
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21-00797-248
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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: 9/19/2024

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

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

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.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

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.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2024

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.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

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.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

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.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

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.

Surgical Adverse Clinical Outcomes and Leaders’ Responses at the Columbia VA Health Care System in South Carolina
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21-03203-239
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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: 5/28/2024

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.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The Columbia VA Health Care System Director ensures providers carefully consider facility resources when evaluating medically-complex patients for admission and when determining whether admitted patients’ medical complexities exceed the facility’s capabilities to meet patients’ needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2023
The Columbia VA Health Care System Director ensures that the peer review committee record the committee members formal discussions specific to the peer review in meeting minutes, and monitors ongoing compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The Columbia VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, ensures current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2023
The Columbia VA Health Care System Director ensures that root cause analyses are completed within the required 45-day time frame to promptly identify and address system vulnerabilities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2023
The Columbia VA Health Care System Director facilitates a comprehensive administrative review of the vascular surgeon’s disregard of surgical and invasive procedure protocols and Stop the Line principles, consults with the Office of Regional Counsel and human resource specialists, and takes administrative actions, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The Columbia VA Health Care System Director evaluates facility staff’s informed consent and time-out practices, to include the review of pertinent medical images, and ensures practices are consistent with correct surgery and invasive procedure requirements, takes action as appropriate, and monitors compliance.
Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2021
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22-00814-230
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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: 12/21/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures healthcare providers inform patients and/or caregivers when a medication is not FDA-approved; provide the option to refuse the medication; and advise them of the known risks, benefits, and alternatives prior to administration.
Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California
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21-03595-219
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Topics:  Care Coordination ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director confirms that a process is in place to ensure community living center staff have knowledge of policies pertaining to nursing practice and documentation in the community living center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2022
The VA Greater Los Angeles Health Care System Director ensures all nursing staff assigned to the community living center have received training on the completion and documentation of all required elements for pain assessments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2022
The VA Greater Los Angeles Health Care System Director verifies that community living center nursing staff demonstrate knowledge of the procedure for managing verbal and telephone orders and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director reviews the Greater Los Angeles Healthcare System hand-off communication policy to determine if changes are warranted to address the procedure for managing hand-offs, ensures understanding of policy by staff, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director verifies that community living center staff are aware of events warranting submission of a Joint Patient Safety Report and how to submit one.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2022
The VA Greater Los Angeles Health Care System Director evaluates the circumstances surrounding the death of the resident and determines if peer reviews of relevant clinical staff are warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The VA Greater Los Angeles Health Care System Director ensures that community living center managers receive training on the types of reviews, including quality assurance and administrative investigations and when each is appropriate for use, and documents attendance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director ensures that actions identified in the Corrective Action Plan are tracked to completion.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The VA Greater Los Angeles Health Care System Director confirms that an institutional disclosure is completed and documented to share that an “opportunity for intervention(transfer to the Emergency Department) existed and was considered but not acted on, prior to the terminal event.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The VA Greater Los Angeles Health Care System Director directs community living center leaders to review policy and admission processes to ensure respiratory therapy equipment needed in the care of a resident is in place at the time of admission.
Deficiencies in Life-Sustaining Treatment Processes at the Michael E. DeBakey VA Medical Center in Houston, Texas
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21-02903-214
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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: 12/15/2022
The Under Secretary for Health reviews vulnerabilities related to life-sustaining treatment processes and do not resuscitate orders within Veterans Health Administration facilities
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director evaluates staff’s reliance on the electronic health record as the definitive source for verification of life-sustaining treatment orders and patients’ code statuses and takes action as indicated
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director ensures that corrective actions from internal and quality management reviews are fully developed, implemented, and monitored for effectiveness.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director ensures that the electronic health record displays life-sustaining treatment orders where staff can easily locate the information.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Michael E. DeBakey VA Medical Center Director ensures that modifications to patients’ life-sustaining treatment orders, including do not resuscitate orders, are confirmed with the patient and surgical team and documented in the electronic health record prior to surgical procedures requiring anesthesia.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2022
The Michael E. DeBakey VA Medical Center Director determines that facility staff review patients’ code statuses for any changes upon patients’ return to units after surgical procedures.
Deficiencies in Facility Leaders’ Oversight and Response to Allegations of a Provider’s Sexual Assaults and Performance of Acupuncture at the Beckley VA Medical Center in West Virginia
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21-03339-208
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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: 12/14/2022
The Capital Health Care Network Director reviews and evaluates the March 2021 Administrative Investigation Board action plan to identify open actions and ensures completion.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Beckley VA Medical Center Director ensures a review of Veterans Health Administration and Beckley VA Medical Center policies related to professional practice evaluations, including supervisory roles, review periods, and service-specific data collection, and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Beckley VA Medical Center Director reviews and evaluates Veterans Health Administration and Beckley VA Medical Center policies related to disclosures and quality management actions such as look-back reviews and patient safety reporting to ensure such actions are timely, objective, and documentation is sufficient to address the issue under review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022
The Beckley VA Medical Center Director ensures staff education of Veterans Health Administration and Beckley VA Medical Center policies related to employee misconduct and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Beckley VA Medical Center Director evaluates processes for reporting providers to the state licensing boards, including initial and comprehensive reviews, and monitors compliance.
Review of Veterans Health Administration’s Response to a Medication Recall
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21-02194-198
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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: 12/7/2022
The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health reviews vulnerabilities in the medication recall process due to variances in Veterans Health Administration medical facility processes and makes changes as necessary.
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm
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22-01137-204
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 2/13/2023

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.

Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia
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21-00287-194
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Topics:  Patient Safety ● Care Coordination ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders properly identify adverse events as sentinel events when criteria are met and conduct institutional disclosures, as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Health Systems Specialist participates on the VISN Systems Redesign Review Advisory Group.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend Facility Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate all patient transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all Employee Threat Assessment Team members complete the required training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2023

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

Pharmacists’ Practices Delayed Buprenorphine Refills for Patients with Opioid Use Disorder at the New Mexico VA Health Care System in Albuquerque
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21-03195-189
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Topics:  Patient Safety ● Mental Health

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2023
The New Mexico VA Health Care System Director ensures that facility practice is consistent with Veterans Health Administration and facility policy applicable to early refills of buprenorphine for patients receiving opioid agonist therapy for opioid use disorder and is consistent with evidence-based treatment and prescribing providers’ clinical rationale, ensures all relevant staff are educated on the policy, and monitors for compliance with policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2023
The New Mexico VA Health Care System Director ensures communication between provider, pharmacist, and patient for early medication refills and monitors for compliance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The New Mexico VA Health Care System Director clarifies the roles and responsibilities of the Opioid Safety Committee as related to buprenorphine treatment for patients with opioid use disorder, and ensures relevant staff are educated regarding the Opioid Safety Committee’s role in buprenorphine treatment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
The New Mexico VA Health Care System Director reviews buprenorphine prescribing provider concerns regarding the Opioid Agonist Therapy (Buprenorphine) for Opioid Use Disorder standard operating procedure and ensures the planned revision and implementation of the standard operating procedure is consistent with evidence-based treatment and includes language that specifies allowance for clinical judgment and a patient-centered care approach.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The New Mexico VA Health Care System Director reviews prescribing provider staffing levels in accordance with the Substance Use Disorder program’s needs and facility’s plans for expanding buprenorphine treatment in other clinical areas, and develops an action plan to address recommendations, if any, from the staffing level review.
Failure of Leaders to Address Safety, Staffing, and Environment of Care Concerns at the Tuscaloosa VA Medical Center in Alabama
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21-03201-185
|
Topics:  Patient Safety ● Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Tuscaloosa VA Medical Center Director provides oversight of the purchase and installation of an electronic alarm system for all Community Living Center neighborhoods and cottages and confirms ongoing monitoring of its use after installation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
The Tuscaloosa VA Medical Center Director confirms completion of the risk analysis recommended in the facility-initiated risk assessment to determine if the Azalea House is suitable for the patient population residing there.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The Tuscaloosa VA Medical Center Director ensures that all security cameras are operable and labeled appropriately and develops and monitors a plan for ongoing testing and maintenance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director directs staff to assess the effectiveness of the outdoor fencing and gates surrounding Azalea House as a security measure to prevent Community Living Center residents at-risk for elopement from leaving the facility campus.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2023
The Tuscaloosa VA Medical Center Director establishes a review process to ensure that Community Living Center residents determined to be high risk for elopement have documentation consistent with Tuscaloosa VA Medical Center policy in their electronic health records identifying residents’ risk status.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director collaborates with the Veterans Integrated Service Network 7 Senior Strategic Business Partner to determine difficult to fill job series and develops a plan to maximize use of available tools for coverage, recruitment, and retention.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director ensures completion of a review of the facility’s Comprehensive Environment of Care program to confirm that patient care areas are properly classified, all areas are inspected at the required frequency, and compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director coordinates with subject matter experts and develops a plan to ensure that the facility’s Comprehensive Environment of Care program effectively identifies areas in need of attention to provide a clean and safe environment for patients, visitors, and staff.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director confirms that Engineering Service staff conduct rounds of the grounds according to Tuscaloosa VA Medical Center policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2023
The VA Southeast Network 7 Director ensures completion of the Tuscaloosa VA Medical Center’s action plan to address recommendations made as a result of the October 2021 Veterans Integrated Service Network site visit.
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia
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21-03349-186
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Topics:  Care Coordination ● Community Care ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2023
The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023

The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director reviews the urology consult template and, if appropriate, ensures the specific imaging required for consultation is specified in the template.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.
Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore
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21-00283-173
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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: 11/22/2022
The Chief of Staff evaluates and determines additional reasons for noncomplianceand ensures that peer reviewers use at least one of the nine aspects of care forevaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures that the Peer Review Committee recommendsimprovement actions for Level 3 peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and makes certain that the Peer Review Committee completes finalpeer reviews within 120 calendar days from the date it is determined a peer reviewis required, or the System Director approves any necessary extensions in writing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders complete all elements of the VA Inter-Facility Transfer Form or afacility-defined equivalent note in the electronic health record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2024

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2024

The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.

Deficits with Metrics Following Implementation of the New Electronic Health Record at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-03020-168
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2024

The Deputy Secretary completes an evaluation of gaps in new electronic health record metrics and takes action as warranted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2024

The Deputy Secretary completes an evaluation of factors affecting the availability of metrics and takes action as warranted.

Failure to Provide Emergency Care to a Patient and Leaders’ Inadequate Response to that Failure at the Malcom Randall VA Medical Center in Gainesville, Florida
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20-04443-167
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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: 10/13/2022
The VA Sunshine Healthcare Network Director ensures a review of the patient incident is conducted to determine whether further administrative action or reporting to state licensing board(s), or both, is warranted for facility staff involved in the incident, and takes action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director ensures that Emergency Department nurses and Administrative Officers of the Day prioritize patient care before patient eligibility status when patients present with an emergency medical condition, holds staff accountable when violations occur, and monitors for ongoing compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director ensures that Emergency Department nurse competencies are current, complete, and validated as required, and monitors for ongoing compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director conducts an internal review of the Emergency Department Nurse Educator’s replication of the 2019 Ongoing Competency Assessments and attestation of competency completion to determine whether administrative action is warranted and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director evaluates the status of action plans referenced in this report and monitors the implementation and efficacy of action items to closure.
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