All Reports

Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin
|
20-00068-206
|
Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures implementation of specific action items are documented in Quality Council minutes when problems or opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum required gastroenterology-specific criteria for focused and ongoing professional practice evaluations of licensed independent practitioners.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures all medical equipment is identified as safe for patient use.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that staff remove expired medications from patient care areas.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy to assess adherence to the therapy plan and effectiveness of treatment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that employees receive initial suicide prevention training within 90 days of hire and annual refresher training thereafter.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
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 to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that traffic flow in the Gastroenterology clean storage areas is restricted.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity requirements are maintained and documented for the Gastroenterology clean storage areas.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff receive competency assessments prior to reprocessing reusable medical equipment.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois
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20-00062-205
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Chief of Staff determines reasons for noncompliance and makes certain that ongoing professional practice evaluations include service-specific criteria and are completed by providers with similar training and privileges.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2021
The System 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 departing the healthcare system.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment on all patients prior to initiating long-term opioid therapy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent consistently for patients prior to initiating long-term opioid therapy. 
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic with documented preference within the required time frame. 
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain staff complete suicide risk and intervention training within 90 days of entering their position and annual suicide prevention refresher training thereafter. 
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director 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 arrangements for leave coverage when there is only one designated provider.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee holds quarterly meetings with required representatives, and report to executive leaders.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with current manufacturers’ guidelines and instructions for use. 
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
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 to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center
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19-07507-214
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director ensures that Emergency Department staff adhere to Veterans Health Administration suicide prevention policies and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director ensures that patients are adequately assessed for withdrawal risk and provided with appropriate disposition for management of withdrawal.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director ensures staff education of the Veterans Health Administration and Washington DC VA Medical Center policies related to employee misconduct and patient abuse, and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2021
The VA Capitol Health Care Network Director reviews Washington DC VA Medical Center leadership and supervisory response to allegations of employee misconduct and patient abuse to determine if administrative action is warranted and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director determines leaders’ authority and duty to report physician 2’s behavior to the State Licensing Board and National Practitioner Data Bank and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director establishes comprehensive quality monitoring of the required hand-off communication processes, including interdisciplinary participation and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director makes certain that Emergency Department staff reconcile diagnostic and care plan information that may vary across providers and shifts when determining a patient’s final disposition.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director ensures that Emergency Department staff include the patient and family members, in the development of a care plan as appropriate, and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Washington DC VA Medical Center Director ensures that facility staff complete Suicide Behavior and Overdose reports as required.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2021
The Washington DC VA Medical Center Director establishes quality monitoring of consult scheduling procedures and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2021
The Washington DC VA Medical Center Director expedites Emergency Department renovations to ensure a safe and secure area for evaluation of mental health patients.
Comprehensive Healthcare Inspection of the John J. Pershing VA Medical Center in Poplar Bluff, Missouri
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19-09416-186
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define and document expectations for focused professional practice evaluations in provider profiles prior to assessment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that first- or second-line supervisors complete provider exit review forms within seven calendar days of a provider’s departure from the medical center.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment that includes a history of substance abuse, psychological factors, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for concurrent opioid and benzodiazepine medication therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff determines the reason for noncompliance and make certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients prior to initiating long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up of patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Interim Medical Center Director determines the reasons for noncompliance and ensures that the Pain Management Sub-Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians conduct four follow-up appointments, either face-to-face or telephonic with documented consent, within the required time frame.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff receive annual suicide prevention refresher training.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Interim Medical Center Director 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 arrangements for leave coverage when CBOCs have only one designated provider.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee is comprised of the required core members.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services 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: 11/19/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka
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19-06870-175
|
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: 12/3/2020
The System Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are documented in Quality, Safety, and Value Board minutes when problems or opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that peer reviewers consistently use at least one of the nine aspects of care for evaluations and address the initial screener’s concern.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths within 24 hours of admission are peer reviewed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date it is determined a peer review is required and any necessary extensions are approved in writing by the System Director.
No. 5
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 a summary of the Peer Review Committee’s analyses is reviewed quarterly by the Medical Executive Board.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The System Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements and be properly documented in the VHA Patient Safety Information System.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in the provider profiles.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum required gastroenterology- and pathology-specific criteria for focused professional practice evaluations of licensed independent practitioners.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that Medical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2023
The System 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’ departing the healthcare system and include the signature of the first- or second-line supervisor in the properly designated area.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures employees’ ability to access safety data sheet information.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director determines the reasons for noncompliance and ensures that clean/sterile storerooms are secured.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures damaged wheelchairs are repaired or removed from service.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director determines the reason(s) for noncompliance and ensures areas are consistently stocked with medical supplies typically needed to meet patient care needs.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and makes certain that panic alarms are tested and that deficiencies identified from the testing are addressed, including staff education.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director determines the reason(s) for noncompliance and ensures that deficiencies observed during Comprehensive Environment of Care Rounds are correctly documented in the Comprehensive Environment of Care Assessment and Compliance Tool and followed until completion.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that Wyandotte County VA Clinic managers maintain a safe and clean environment by addressing the deficiencies identified by the inspection.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients who are initiating long-term opioid therapy.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator ensures completion of at least five outreach activities each month.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines reasons for noncompliance and ensures that mental health providers consistently contact or attempt to contact patients flagged as high risk for suicide who miss mental health or substance abuse appointments and properly document those efforts.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and reasons for noncompliance and makes certain that the mental health provider and the Suicide Prevention Coordinator collaborate to determine next steps for patients flagged as high risk for suicide when attempted contact is unsuccessful after missed mental health or substance abuse appointments.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff determines the reason(s) for noncompliance and ensures that Suicide Prevention Safety Plans include an assessment of patients’ access to opioids and a discussion of safety and overdose risks.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that each CBOC has at least two designated women’s health primary care providers or arrangements for leave coverage when CBOCs have only one designated provider.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend the Women Veterans Health Committee that meets at least quarterly and reports to executive leaders.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Service Chief maintains an accurate file for all reusable equipment that includes current manufacturers’ instructions for use.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures are kept current and maintained as required, which includes alignment with manufacturers’ guidelines and instructions for use, review at least every three years, and update when there is a change in process or the manufacturer’s instructions for use.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs an annual risk analysis and reports the analysis to the Veterans Integrated Service Network Sterile Processing Service Management Board.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is reprocessed.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are stored properly.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines reasons for noncompliance and ensures that all current Sterile Processing Services employees complete Level 1 training and all new employees complete Level 1 training within 90 days of hire.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines reasons for noncompliance and ensures that the Chief of Sterile Processing Services documents completion of competencies for staff prior to performance of reprocessing duties.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota
|
19-00468-67
|
Topics:  Suicide Prevention ● 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: 7/24/2020
The Minneapolis VA Health Care System Director ensures that Emergency Department staff notify the facility Suicide Prevention Coordinator when a patient presents with suicidal ideation, as required by the Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care, including consults, and considers whether an institutional disclosure is warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that inpatient consult results are acted upon by the responsible provider or appropriate designee and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director strengthens processes in root cause analyses consistent with Veterans Health Administration requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Under Secretary for Health ensures that the Veterans Health Administration establishes written guidance for root cause analysis teams to identify lessons learned and expectations regarding related actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that the Patient Safety Committee and Quality Management Council meeting minutes include deliberations and tracking of actions to resolution, as required by Veterans Health Administration and facility policy.
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