All Reports

Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio
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21-03525-148
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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: 9/16/2022
The Chillicothe VA Medical Center Director ensures urgent care providers, chiropractors, and clinical massage therapists are educated on consult processes and procedures and the requirement of timely documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2022
The Chillicothe VA Medical Center Director conducts an internal review of the Complementary and Alternative Medicine Program processes related to patient care including receiving and reviewing consults, scheduling appointments, checking-in patients for care, and documentation.
Deficiencies in the Care of a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia
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21-01048-154
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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: 3/1/2023
The Veterans Integrated Service Network Director reviews the primary care provider’s care of the patient in the year prior to surgery and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director ensures patient aligned care team nurses are aware of and comply with the Veterans Health Administration patient aligned care team policy including requirements for same-day access.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2023
The Charlie Norwood VA Medical Center Director ensures patient aligned care team physicians are aware of and comply with the Veterans Health Administration directive regarding communication of test results to patients including time frames and communication of associated treatment plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director ensures that surrogates are assigned for patient aligned care team nurses while they are on leave.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director reviews the patient’s preoperative care, including additional quality reviews, and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director reviews medical-surgical unit nurses’ care of the patient and takes action as warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director evaluates the use of the Trendelenburg position in inpatient areas and provides education to all facility nursing staff on the potential risks of and indications for use.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Charlie Norwood VA Medical Center Director ensures that all medical-surgical unit nurses demonstrate competency to provide adequate alcohol withdrawal care and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director implements controls to ensure care provided by medical-surgical unit nurses is of an acceptable quality.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Charlie Norwood VA Medical Center Director ensures that the Charlie Norwood VA Medical Center alcohol withdrawal treatment protocol is specific, does not conflict with physicians’ orders, and aligns with the probable onset of patients’ alcohol withdrawal symptoms.
Comprehensive Healthcare Inspection of the Northport VA Medical Center in New York
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21-00300-130
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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: 10/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff conduct a peer review for all applicable deaths that occur within 24 hours of admission.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses at the time of initial application.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Associate Director for Patient Care Services determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Comprehensive Healthcare Inspection of the VA New Jersey Health Care System in East Orange
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21-00296-145
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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 Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality Leadership Council.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends individual improvement actions, and clinical managers implement the committee’s recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days from the date it is determined a peer review is required or have a written extension request approved by the Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits quarterly summaries of peer review data for review by the Executive Committee of the Medical Staff.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets at least monthly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain all inter-facility transfers are monitored and evaluated as part of the Veterans Health Administration’s Quality Management Program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Facility Leaders’ Response to Inappropriate Mental Health Provider-Patient Relationships at the VA Illiana Health Care System in Danville, Illinois
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19-08364-140
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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: 9/27/2022
The Veteran Integrated Service Network 12 Director evaluates processes that affected facility supervisors’ initial efforts to identify and address facility mental health providers’ inappropriate relationships and takes actions as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The VA Illiana Health Care System Director reviews the process for reporting providers to state licensing boards or state certification boards and makes appropriate changes as deemed necessary to ensure timely reporting.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The VA Illiana Health Care System Director reviews Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted
Comprehensive Healthcare Inspection of the Syracuse VA Medical Center in New York
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21-00294-128
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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 Medical Center Director determines the reasons for noncompliance and makes certain that leaders identify adverse events as sentinel events when criteria are met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that leaders conduct institutional disclosures for all sentinel events.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator consistently participates in Veterans Integrated Service Network Systems Redesign Review Advisory Group meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group meets monthly and core members consistently attend meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group analyzes efficiency and utilization metrics and evaluates critical surgical events.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2023
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.
Quality of Care Concerns and Leaders’ Responses at the Amarillo VA Health Care System in Texas
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21-02491-129
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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: 6/1/2023
The Amarillo VA Healthcare System Director ensures Emergency Department staff follow established protocols for clinical assessment, frequency, and intervention regarding abnormal vital signs, and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Amarillo VA Healthcare System Director completes an evaluation of the registered nurse’s failure to ensure the patient received urgent medical attention after presenting to the clinic with stroke-like symptoms and takes appropriate action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Amarillo VA Healthcare System Director reiterates expectations that patient aligned care team staff engage in respectful communications with patients and their families, and monitors patient advocate data as well as patient satisfaction survey data for evidence of compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Amarillo VA Healthcare System Director completes a retrospective review of critical view alerts and other quality of care elements of the subject provider for the two years immediately preceding the subject provider’s summary suspension, takes clinical and administrative actions in accordance with Veterans Health Administration guidelines, and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Amarillo VA Healthcare System Director ensures patient aligned care team staff follow communication protocols and electronic health record documentation requirements, and monitors for compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The Veterans Integrated Service Network Director evaluates the system leaders’ actions in this case related to ongoing professional practice evaluation and focused professional practice evaluation for cause processes, focused clinical care review, and institutional disclosure; takes action related to staff training and other identified deficits, as needed; and monitors for compliance.
Noncompliant and Deficient Processes and Oversight of State Licensing Board and National Practitioner Data Bank Reporting Policies by VA Medical Facilities
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20-00827-126
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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: 2/23/2024

The Under Secretary for Health reviews the State Licensing Board reporting processes at the facility level to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the National Practitioner Data Bank facility reporting practices align with federal regulations and Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Under Secretary for Health instructs facility directors to submit National Practitioner Data Bank reports regarding physicians and dentists consistent with Veterans Health Administration policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2025

The Under Secretary for Health ensures programmatic oversight of facility State Licensing Board and National Practitioner Data Bank reporting processes.

Comprehensive Healthcare Inspection of the VA Western New York Healthcare System in Buffalo
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21-00290-116
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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: 11/29/2022
The Director evaluates and determines the reasons for noncompliance and makes certain that leaders accurately identify and report adverse events as sentinel events when criteria are met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Surgical Work Group meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Chief of Staff and Associate Director for Patient/Nursing 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: 9/9/2022
The Chief of Staff and Associate Director for Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete the required training.
Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina
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21-00282-111
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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: 11/17/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all sentinel events.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Medical Center Director determines the reasons for noncompliance and ensures the Systems Redesign Manager participates on the Veterans Integrated Service Network Systems Redesign Review Advisory Group.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members regularly attend Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2023

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training.

Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-00656-110
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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: 4/9/2024

The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.

No. 2
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.

Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-00781-109
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/2/2023

The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.

Ticket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-00781-108
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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 Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/3/2023

The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/19/2022

The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.

Comprehensive Healthcare Inspection of the Salem VA Medical Center in Virginia
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21-00281-100
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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: 6/23/2023
The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that staff monitor and evaluate inter-facility patient transfers as part of VHA’s Quality Management Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2023

The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.

Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia
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21-00280-89
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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: 10/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete a final peer review within 120 calendar days from the date it is determined that a peer review is needed, or the Medical Center Director approves an extension request in writing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure transferring providers complete all required elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent prior to patient transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
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 area.
Comprehensive Healthcare Inspection of the James J. Peters VA Medical Center in Bronx, New York
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21-00289-90
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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: 3/3/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits a quarterly summary analysis for review by the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Facility Surgical Workgroup meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Facility Surgical Workgroup reviews surgical deaths and evaluates critical surgical events as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2022
The Chief of Staff and Nurse Executive (ADPCS/Chief Nurse Executive) evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
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.
Lack of Care Coordination and Hepatocellular Carcinoma Surveillance of a Patient at the VA Eastern Colorado Health Care System in Aurora
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21-02492-77
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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: 9/28/2022
The VA Eastern Colorado Health Care System Director reviews the transition in care process for patients transferring between primary care providers to ensure continuous care that facilitates communication and avoids missed opportunities, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The VA Eastern Colorado Health Care System Director ensures that providers develop and update patient problem lists as required and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The VA Eastern Colorado Health Care System Director ensures that primary care providers are educated on the expectations of reviewing a patient’s electronic health record when assuming care of an established patient.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient’s care by the primary care providers, determines if an adverse event occurred, and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2022
The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient identified during the inspection who did not receive hepatocellular carcinoma surveillance or varices monitoring, determines if an adverse event occurred, and takes action as warranted.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2023
The VA Eastern Colorado Health Care System Director ensures that patients requiring hepatocellular carcinoma surveillance and varices monitoring receive the recommended imaging studies, lab tests, and esophagogastroduodenoscopies, and monitors compliance.
Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01507-61
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Topics:  Patient Safety ● Mental Health

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers complete aberrant behavior risk assessments on all patients prior to initiating long-term opioid therapy.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers communicate problematic urine test results to patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers follow up with patients within three months after initiating opioid therapy to assess adherence to the pain management plan of care and effectiveness of interventions.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities monitor the quality of pain assessment and effectiveness of pain management interventions.

Deficiencies in a Patient’s Lung Cancer Screening, Renal Nodule Follow-Up, and Prostate Cancer Surveillance at the VA Southern Nevada Healthcare System in Las Vegas
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21-01038-49
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The VA Southern Nevada Healthcare System Medical Center Director reviews primary care and pulmonology processes to ensure patients with high-risk factors for lung cancer receive screening and follow-up care and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
The VA Southern Nevada Healthcare System Medical Center Director implements processes to ensure that patients with abnormal radiology findings have appropriate follow-up and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The VA Southern Nevada Healthcare System Medical Center Director ensures that providers follow the guidelines for surveillance for patients who have undergone prostatectomy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA Southern Nevada Healthcare System Medical Director reviews primary care providers’ copy and paste practices, implements processes to ensure a current plan of care is documented in the electronic health record, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA Southern Nevada Healthcare System Medical Center Director reviews the complaint reporting and responding processes, ensures complaints are addressed in accordance with Veterans Health Administration policy, and monitors compliance.
Deficiencies in the Care of a Patient with Gastrointestinal Symptoms at the Eastern Oklahoma Health Care System in Muskogee
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21-01801-45
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Eastern Oklahoma VA Health Care System Facility Director reviews processes to ensure patients with ordered Fecal Immunochemical Test (FIT) are tracked according to Veterans Health Administration policy, documentation is complete, and takes action if necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Eastern Oklahoma VA Health Care System Facility Director evaluates processes for Emergency Department providers’ physical examinations when a patient presents with gastrointestinal symptoms that include associated bleeding and determines if modifications, including provider education, are needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2022
The Eastern Oklahoma VA Health Care System Facility Director ensures that patient advocates and Primary Care leaders perform thorough reviews of all components of complaints for resolution and patient advocates document according to policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Eastern Oklahoma VA Health Care System Facility Director ensures facility leaders monitor complaints and take action on issues that are identified related to the Emergency Department physician’s performance.
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