All Reports

Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida
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20-03535-146
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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: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.
Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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18-02496-157
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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: 6/5/2023
The Under Secretary for Health ensures that the Veterans Health Administration competency process for locum tenens, newly hired specialty care providers, and newly hired service chiefs is evaluated to confirm that the results of the assessment accurately reflects the clinical competency of providers who are privileged, and takes action, as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health reviews current Veterans Health Administration credentialing and privileging policies to assess guidance related to service chiefs’ ongoing professional practice evaluation and takes action, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health reviews Veterans Health Administration policies to ensure that if facility leaders elect to incorporate pathology 10 percent peer reviews into the performance evaluations of a Pathology and Laboratory Medicine Service Chief, those reviews are performed by a peer without a conflict of interest and takes action, as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2022
The Under Secretary for Health evaluates the use and methodology of the Pathology and Laboratory Medicine Service 10 percent peer review for effectiveness as a quality management tool, and takes action, as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration guidance related to amended pathology reports’ terminology, use, and entry of such reports into patients’ electronic health records, and revises guidance, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health confirms that provisions are included in the Veterans Health Administration record modernization program that ensure amended pathology report alerts are directed to designated facility staff and leaders.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration quality management processes related to external, non-VHA pathology consultant assessments and ensures that facility leaders, the specialty care provider, and requesting providers are notified of the results of such reviews and a tracking process is in place.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Under Secretary for Health confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, & Preparedness to determine whether administrative action is warranted for Veterans Health Administration leaders who did not adequately perform their duties with respect to the issues within this report, and takes action, as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2023
The Under Secretary for Health explores the development of a mandatory alcohol testing policy for individuals including healthcare workers who perform functions that would put patients at risk should the employee work while impaired.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Under Secretary for Health evaluates Veterans Health Administration’s guidance related to impaired healthcare workers and ensures that it addresses the circumstances under which alcohol and or drug testing may be performed; the extent of a retrospective review of care if one is indicated; and the availability of advisors who are knowledgeable on the management of an impaired provider, and takes action, as indicated.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director verifies that peer references obtained during the reappraisal and reprivileging processes are in alignment with VHA Handbook 1100.19, Credentialing and Privileging.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director evaluates the psychological safety climate to ensure facility staff, patients, and the general public are empowered to report concerns and unsafe patient care without fear of reprisal and takes action, as needed.
Comprehensive Healthcare Inspection of the Chillicothe VA Medical Center in Ohio
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20-01268-143
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Topics:  Suicide Prevention ● 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: 10/27/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analysis is reviewed quarterly by the Medical Staff Executive Council.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager monitors implemented root cause analysis action items for sustained improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff determines the reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare professional’s first- or second-line supervisor correctly completes and signs an exit review form within seven business days of the professional’s departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Opioid Safety Review Board monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete suicide prevention training as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required Women Veterans Health Committee members are assigned and consistently attend meetings, and that the committee reports to the Medical Staff Executive Council.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures standard operating procedures are current, align with manufacturers’ guidelines/instructions for use, and are reviewed at least every three years or when there is a change.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that all Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employee competency assessments align with medical center standard operating procedures.
Drug Interactions Related to a Patient Death, Marion VA Medical Center in Illinois
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20-03380-136
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Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2022
The Marion VA Medical Center Director ensures that behavioral health staff provide, and document patient education including discussion of side effects and possible adverse drug-drug interactions during telephone encounters when medications are added or adjusted and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2022
The Marion VA Medical Center Director confirms that behavioral health providers are communicating test results to patients and providing necessary clinical interventions as required by policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Marion VA Medical Center Director monitors implementation of Phase Four of the Psychotropic Drug Safety Initiative.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Marion VA Medical Center Director ensures that primary care providers enter return-to-clinic orders and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2022
The Marion VA Medical Center Director verifies primary care and behavioral health staff document contacts, attempted contacts, and letters sent when patients missed their appointments and monitors compliance.
Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in Ohio
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20-01276-131
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, and Value Committee fully implements and monitors improvement actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that all applicable deaths are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2022
The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria for focused professional practice evaluations in practitioner profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs document the results of focused professional practice evaluations in practitioner profiles.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs collect service-specific ongoing professional practice evaluation data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs recommend continuation of privileges based on ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend initiation and continuation of privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the medical center.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinicians complete suicide prevention safety plans in the expected time frame for patients with High Risk for Suicide Patient Record Flags.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or plans for leave coverage if there is only one designated provider.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Advisory Committee meetings.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturer’s instructions for use.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that CensiTrac® is fully operational.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services maintains written records of weekly eyewash station function testing.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment receive monthly continuing education.
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma
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20-03886-141
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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: 5/18/2021
The Oklahoma City VA Health Care System Director ensures a review of the clinic note for the patient who experienced temporary loss of vision and confirms that the level of supervision provided by the attending ophthalmologist is accurately reflected in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2021
The Oklahoma City VA Health Care System Director conducts a review to ensure that language used to document resident supervision accurately reflects the presence of the attending ophthalmologist and the degree of resident oversight provided and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Oklahoma City VA Health Care System Director confirms that ophthalmology service procedures include a hand-off process to address attending coverage in situations when an attending ophthalmologist is unavailable to provide timely resident supervision.
Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia
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20-03593-140
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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: 3/31/2022
The Under Secretary for Health ensures actions are taken to clarify and broadly disseminate adjudicator expectations for follow-up of an unreturned INV Form 41.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Louis A. Johnson Medical Center Director ensures Pharmacy Service utilizes the required Veterans Health Information Systems and Technology Architecture Automatic Replenishment System to record medication usage data and maintain the records for inventory accountability.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Veterans Integrated Service Network 5 Director conducts management reviews of the care of patients 1–10 as discussed in this report and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director reviews the availability and timeliness of endocrinology consults, and takes any corrective action needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Veterans Integrated Service Network 5 Director ensures evaluation of quality of care concerns or other irregularities (beyond hypoglycemia) of: cases provided by the OIG; cases that may otherwise be pertinent or concerning; and cases brought forward by patients and/or family members who express concerns or make other inquiries about care they received from Ms. Mays. As determined by the VISN, clinical experts external to the facility should be utilized when appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director develops and disseminates guidance on clinical communication(s) to ensure that patient care and outcomes are routinely discussed in appropriate forums, such as interdisciplinary team meetings, and the discussions are documented.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures that close observation documentation is readily available in the electronic health record, and monitors for compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures clinical documentation reviews are completed timely for patient safety and continuity of care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director evaluates the factors and processes surrounding employees’ failures to report and follow up on the unexplained hypoglycemic events, and takes action to ensure appropriate reporting of actual or potential patient safety events, system vulnerabilities, or other unexpected events that offer opportunities for lessons learned.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson Medical Center Director requires that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures that the interdisciplinary mortality review workgroup meet as required with appropriate reporting through oversight council(s), and monitors for compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson Medical Center Director ensures that oversight and reporting practices align with Louis A. Johnson Medical Center policy requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Under Secretary for Health determines the potential advantage of a rescue medication flagging system as an additional tool to evaluate unexplained adverse patient events, including but not limited to mortalities, and takes action as indicated.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director takes action to prioritize and continue efforts to promote a strong culture of safety, such as periodic facility-wide refresher patient safety training or additional patient safety stand downs when indicated, and monitors for effectiveness.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The Under Secretary for Health reevaluates how the Veterans Health Administration collects, reviews, and analyzes mortality data from VA facilities, and takes action to address identified gaps and weaknesses, as indicated.
Deficiencies in Leaders’ Responses to Lapses in Reusable Medical Equipment Reprocessing at the Chillicothe VA Medical Center in Ohio
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20-02265-100
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Topics:  Patient Safety ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chillicothe VA Medical Center Director develops an oversight plan to address concerns regarding the employee’s compliance with Sterile Processing Services’ procedures as identified by facility and Veterans Integrated Services Network leaders and the Clinical Episode Review Team and confirms effective resolution.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2021
The Under Secretary for Health ensures that the Clinical Episode Review Team reviews the OIG-provided biomedical equipment manufacturer’s information for the automated endoscope reprocessor to determine if the information alters their determination regarding the potential risk to patients or the need for a large-scale disclosure and takes action as necessary.
Deficiencies in Community Living Center Practices and the Death of a Patient Following Elopement from the Chillicothe VA Medical Center in Ohio
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20-01523-102
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Topics:  Mental Health ● Patient Safety ● VA Police

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Veterans Integrated Service Network Director consults with the VA Office of Mental Health and Suicide Prevention to review the classification and commitment of patients to the long-stay mental health recovery unit in the facility’s community living center, and makes recommendations to ensure the provision of safe mental health care to patients at the Chillicothe VA Medical Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s calendar year 2019 mental health care, including psychiatric care and medication management, and makes recommendations to the facility, if indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chillicothe VA Medical Center Director establishes a review process to ensure that community living center assessments clearly align the service offerings of the community living center with the individual needs of patients.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chillicothe VA Medical Center Director ensures development of a process to address the care needs of patients who are determined inappropriate for community living center admission.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2021
The Chillicothe VA Medical Center Director establishes a review process to ensure that community living center care plans are consistent with applicable Veterans Health Administration policy and communicated to the community living center staff caring for patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director ensures all community living center long-stay mental health recovery unit staff receive mental health training and pass competency evaluations to provide care specific to the needs of the population served.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director ensures that all facility staff are trained on, and comply with, the facility policy concerning patient behavior management.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2022
The Chillicothe VA Medical Center Director ensures that all facility community living center staff report near-miss and actual missing patient events to patient safety staff and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2021
The Chillicothe VA Medical Center Director ensures that patient safety staff review reported events for patterns or trends indicating risks to patients with a need for mitigation and confirms that effective mitigation strategies are initiated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chillicothe VA Medical Center Director ensures all facility community living center staff receive initial orientation on how to prevent and respond to missing patient events, activating all alerts and involving all relevant staff, as required.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director reviews the facility’s policy on missing patients, ensures that it clearly outlines actions staff should take to prevent missing patient events, and verifies that relevant staff are trained and knowledgeable about such actions.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021
The Chillicothe VA Medical Center Director ensures that VA police officers receive training and resources to provide missing patient alerts to all facility staff and appropriate law enforcement agencies.
Quality of Colonoscopies in Multispecialty Community-Based Outpatient Clinics
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20-01386-107
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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: 6/2/2022
The Under Secretary for Health clarifies requirements for colonoscopy quality indicators for professional practice evaluation and ensures a process is in place to monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2023
The Under Secretary for Health strengthens requirements for colonoscopy quality assurance monitoring that includes analysis of quality indicators to identify trends and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2022
The Under Secretary for Health, in conjunction with the National Gastroenterology Program Director, evaluates implementation of standardized endoscopy software across Veterans Health Administration facilities where colonoscopies are performed and takes action as indicated.
View Alert Process Failures and the Impact on Patient Care at the Central Alabama Veterans Health Care System in Montgomery
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20-00427-92
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Topics:  Patient Safety ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health maintains consistent acting or interim leaders and expedites hiring of permanent leaders at the Central Alabama Veterans Health Care System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The VA Southeast Network Director ensures continued collaboration with the Central Alabama Veterans Health Care System to facilitate compliance with guidelines related to view alert management and monitors for ongoing efficiency and sustainability.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director will continue to evaluate and assess the Central Alabama Veterans Health Care System’s view alert management process, effectiveness of its action plan, and modify as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The Central Alabama Veterans Health Care System Director ensures that initial and ongoing provider training and support for the clinical management of view alerts is provided, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director issues guidance and ensures providers are trained on a clearly defined process for the designation of surrogates and the associated responsibilities, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director evaluates the two cases discussed in this report to determine if an institutional disclosure or formal quality management review is needed and takes action accordingly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on the unmanaged abnormal laboratory test and imaging results to include those that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on unscheduled community care consults that were discontinued after 90 days that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director ensures the development and implementation of a policy to address the communication of all test results to ordering providers, or designee, and to patients as required by Veterans Health Administration policy, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director ensures that audits of abnormal laboratory and imaging test results, and unscheduled community care consults that were discontinued after 90 days, are completed to verify providers have managed the associated view alerts, and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director ensures that pending actions are completed for the 33 patient cases with clinical issues referred to the system by the Office of the Inspector General.
Colonoscope Reprocessing at Multispecialty Community-Based Outpatient Clinics
|
20-01387-89
|
Topics:  Patient Safety ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2022
The Under Secretary for Health requires facility directors ensure that staff who reprocess colonoscopes at community-based outpatient clinics complete initial training within the required 90 days prior to independently reprocessing equipment and maintain documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2022
The Under Secretary for Health requires facility directors confirm that sterile processing services staff who reprocess colonoscopes at community-based outpatient clinics receive ongoing continuing education through monthly in-services and maintain documentation.
Mammography Program Deficiencies and Patient Results Communication at the Washington DC VA Medical Center
|
20-00563-68
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates documentation processes for entering the Breast Imaging-Reporting and Data System as primary diagnostic codes in the electronic health record and takes actions as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2023
The Washington DC VA Medical Center Director evaluates the processes for notification of mammography exam results by ordering providers and takes actions as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director fully implements action plans for all issues listed in the September 2019 National Radiology Program Office site visit and monitors to completion.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2021
The National Radiology Program Office ensures mammography programs have a comprehensive standard operating procedure manual and confirms compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director develops and implements a comprehensive standard operating procedure manual covering critical technical, clerical, and administrative functions for the facility’s Mammography Program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates the oversight and training processes for the facility’s Mammography Program medical support assistant and takes actions as necessary.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates mammography technology staff training processes and takes actions to ensure mammography technology staff receive training through a formalized program.
VHA’s Response following Cardiac Catheterization Lab Closure at the Samuel S. Stratton VA Medical Center in Albany, New York
|
19-09129-76
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Under Secretary for Health should publish written guidance that clarifies roles and responsibilities of the national Cardiology program office, Veterans Integrated Service Networks, and Chief Medical Officers to review and opine on interventional cardiologist applicant’s qualifications for employment in those cases when facilities lack local interventional cardiology expertise and the facility’s Chief of Staff seeks subject matter expert opinion.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
Misconduct by a Gynecological Provider at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi
|
20-01036-70
|
Topics:  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 Under Secretary for Health initiates review of policies related to the role and training requirements of providers, including gynecologists, who conduct sensitive exams, to determine the need for the inclusion of trauma-informed care principles into training, policy, and practice.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures a review of policies related to the role and training requirements of chaperones for sensitive examinations and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The South Central VA Health Care Network Director evaluates processes for tracking patient complaints, takes appropriate action to ensure that facility staff enter all complaints into the Patient Advocate Tracking System, and ensures that the data are tracked, trended, and analyzed to identify significant issues and trends.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Gulf Coast Veterans Health Care System Director ensures staff education of the Veterans Health Administration and Gulf Coast Veterans Health Care System policies related to employee misconduct and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Gulf Coast Veterans Health Care System Director reviews and evaluates policies related to administrative investigations, including fact-finding reviews and administrative investigation boards, to ensure such investigations are timely, objective, and documentation is sufficient to address the event under review.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Gulf Coast Veterans Health Care System Director and facility leaders review the subject gynecologist’s conduct and quality of care provided and meet all Veterans Health Administration requirements for state licensing board and National Practitioner Data Bank reporting.
Thoracic Surgery Quality of Care Issues and Facility Leaders’ Response at the C.W. Bill Young VA Medical Center in Bay Pines, Florida
|
18-01321-56
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Under Secretary for Health designates a thoracic specialty leader who has the authority to review all aspects of the personnel and management actions and can provide unbiased, authoritative, and timely guidance to facilities on the most clinically sound course of action when a thoracic surgeon’s practice or outcomes are under review, in order to ensure that VA provides high quality care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Under Secretary for Health outlines general parameters and triggers for when facilities without local thoracic surgery expertise engage the thoracic specialty leader and how the thoracic specialty leader’s decisions and guidance will be documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2022
The Under Secretary for Health clarifies Veterans Health Administration policy regarding providers’ responsibilities to document complications in operative reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The Under Secretary for Health reevaluates the eligible and mandatory assessment surgery cases reported to the National Surgery Office to determine if thoracic cases should be included in the list of mandatory assessment cases, and modifies the list as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The Under Secretary for Health defines expectations for peer review committee members whose cases are being reviewed to leave the room during those deliberations, provides guidance on how that recusal is to be annotated in the Peer Review Committee minutes, and updates Veterans Health Administration policy, as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The C.W. Bill Young VA Medical Center Director enhances processes to identify the existence of omissions or misrepresentations in operative note documentation and takes action based on identified deficiencies, if any.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The C.W. Bill Young VA Medical Center Director takes action to ensure that the surgeon is aware of, and complies with, expectations for professional communications and supporting staff to report adverse events and close calls.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The C.W. Bill Young VA Medical Center Director ensures the C.W. Bill Young VA Medical Center Surgical Work Group provides oversight as required by Veterans Health Administration policy and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The C.W. Bill Young VA Medical Center Director confirms processes are in place to ensure providers’ clinical privileges are specific to the facility and service, and are based on each provider’s clinical competence, and monitors for compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2021
The C.W. Bill Young VA Medical Center Director reviews whether the cases reflected in tables 1 and 2 in this report meet criteria for institutional disclosure and takes action as appropriate.
Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center in Augusta, Georgia
|
20-00132-28
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, Value, and Innovation Council monitors implemented improvement actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths that occur within 24 hours of admission are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Medical Center Director determines the reasons for noncompliance and ensures the Patient Safety Manager or designee provides feedback to staff who submit patient safety incidents that result in a root cause analysis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Police conducts a physical security evaluation of the Emergency Department.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Assistant Director determines the reasons for noncompliance and ensures signage is in place for all areas where biohazards are present.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Assistant Director determines the reasons for noncompliance and ensures that occupational exposure to hazardous materials is minimized in decontamination areas.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the Athens VA Clinic.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Associate Director determines the reasons for noncompliance and ensures that the medication room and housekeeping supply closet at the Athens VA Clinic are secured at all times.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that personally identifiable information is protected at the Athens VA Clinic.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The Chief of Staff determines the reasons for noncompliance and ensures that policies and procedures are in place for 24 hours a day, 7 days per week gynecological care.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The Chief of Staff determines the reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when only one designated provider is available.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures the medical center has a designated women’s health clinical liaison at each community-based outpatient clinic.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ instructions for use.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and make certain that the Sterile Processing Services staff properly store high-level disinfected endoscopes.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new employees complete Level 1 training within 90 days of hire.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services staff receive properly completed competency assessments prior to reprocessing reusable medical equipment.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
Surgical Service Care Deficiencies in the Critical Care Unit at the Charlie Norwood VA Medical Center in Augusta, Georgia
|
20-01480-31
|
Topics:  Care Coordination ● Supplies and Equipment ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The Charlie Norwood VA Medical Center Director evaluates the effectiveness of the current algorithms for critical care unit nurses and surgical intensivists involving post-operative patients and communication with tele-intensive care unit staff during off-hours, and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The Charlie Norwood VA Medical Center Director confirms the current on-call policy is evaluated and modified as appropriate to include specific telemedicine intensive care unit processes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The Charlie Norwood VA Medical Center Director ensures development of a written plan to address responsibilities of medicine and surgery staff caring for post-operative patients in the Critical Care Unit.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The Charlie Norwood VA Medical Center Director requires critical care unit staff receive training on patient safety reporting and review processes, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The Charlie Norwood VA Medical Center Director ensures the coordination between the facility quality management and telemedicine intensive care unit staff on required patient care reviews, and evaluates compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The Charlie Norwood VA Medical Center Director requires that current and new critical care unit staff receive telemedicine intensive care unit initial orientation and competency training, and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2021
The Veterans Integrated Service Network 10 Telemedicine Intensive Care Unit Program Medical Director requires telemedicine intensive care unit staff training on patient safety reporting and patient care review processes, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2021
The Veterans Integrated Service Network 10 Telemedicine Intensive Care Unit Program Medical Director ensures the telemedicine intensive care unit and facility quality management staff coordinate on required patient care reviews, and evaluates compliance.
Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019
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20-01994-18
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing ● Military Sexual Trauma

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility-level senior leaders, ensures that summaries of the peer review committees’ work are reviewed quarterly by medical executive committees.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all applicable deaths within 24 hours of admission are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that cardiopulmonary resuscitation committees review each resuscitative episode under the facilities’ responsibility and include required elements in reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures focused professional practice evaluation criteria are defined in advance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff document the decision to recommend continuing licensed independent practitioners’ privileges based on ongoing professional practice evaluation results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that service chiefs’ privileging determinations are based, in part, on ongoing professional practice evaluation activities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that ongoing professional practice evaluations use assessments by providers with similar training and privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames for focused professional practice evaluations for cause with licensed independent practitioners.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that inventories of resources and assets that may be needed during an emergency are documented and reviewed annually.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that monthly and quarterly controlled substances inspection reports are reviewed at least quarterly by the facility committees responsible for quality oversight.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that electronic access for monitoring and performing controlled substances balance adjustments is limited to appropriate staff.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete monthly physical inspections of controlled substances storage areas on the day initiated.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify that drugs listed on the “Destructions File Holding Report” are secured and documented and that there is a corresponding sealed evidence bag for each medication during monthly inspections.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify the inventory count for prescription pads on the day of monthly pharmacy inspections.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify written controlled substances prescriptions during monthly area inspections.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify pharmacy vault inventory at the required frequency.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete emergency drug cache inspections that include checks for lock tampering and verification of lock numbers.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement processes for reviewing automated drug dispensing cabinet override reports.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2020
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators establish and monitor related training.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2020
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators communicate related issues, services, and initiatives to facility leaders.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures mental health and primary care providers complete mandatory military sexual trauma training within the required time frame.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians provide and document education on newly prescribed medications and assess patient/caregiver understanding of the information provided.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians review and reconcile patients’ medications and maintain and communicate accurate medication information in electronic health records.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2021
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that women veterans health committees include required core members, meet at least quarterly, and report to leadership.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement quality assurance processes that include tracking of cervical cancer screening notification and follow-up care.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that urgent care centers operating 24 hours a day, 7 days a week have an approved waiver from the National Director of Emergency Medicine.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that emergency departments and urgent care centers are staffed with a minimum of two registered nurses during all hours of operation.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure clinical managers maintain a backup call schedule for emergency department and urgent care center providers.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that support services, including social work, are available to emergency departments and urgent care centers during all hours of operation.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities use appropriate signage to direct patients to emergency departments and urgent care centers.
Deficiencies in Ambulatory Care Center and Emergency Department Processes at the VA Loma Linda Healthcare System in California
|
19-08411-12
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2021
The VA Loma Linda Healthcare System Director ensures that mental health clinic nursing staff are trained on documentation requirements when providing patient care and monitors compliance with training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The VA Loma Linda Healthcare System Director reviews the facility’s hand-off communication policy to ensure that nursing staff are aware of all circumstances in which hand-off communication must occur and takes action as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2021
The VA Loma Linda Healthcare System Director ensures that all nurses filling the first look nurse role obtain and document each patient’s vital signs within 10 minutes of the patient’s arrival to the Emergency Department and monitors compliance.
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