All Reports

The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.

The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers’ recommendations.

The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.

The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.

The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.

Facility leaders ensure staff perform preventive maintenance in accordance with manufacturers’ guidelines and clearly define staff responsibilities.

Executive leaders continue to recruit a permanent chief of biomedical engineering and implement processes to prevent repeat environment of care findings.

The Executive Director oversees improvements to the telephone system to ensure identified vulnerabilities are addressed.

Facility leaders ensure exit signs lead to an exit.

Facility leaders install detectable warning surfaces anywhere a walkway transitions into a roadway.

The Executive Director ensures staff keep patient care areas clean and safe.

Facility leaders ensure staff conduct a risk assessment for electrical cord management to identify and implement any needed improvements.

The Executive Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present and store clean and dirty items separately.

The Executive Director ensures prompt disposal of biohazardous waste.

Facility leaders ensure staff conduct a risk assessment on liquid nitrogen use and storage, to include devices in exam rooms, and implement changes accordingly.

The Executive Director ensures the Comprehensive Environment of Care Committee identifies at least one facility-specific environment of care trend and establishes a performance improvement plan, including outcome measures, to address it.

Facility leaders ensure staff develop service-level workflows for the communication of test results for each service.

Facility leaders review the test result communication policy to ensure it complies with the VHA requirement for communicating critical results outside of normal business hours.

Facility leaders develop a formal process for staff to track performance metrics for test result communication, implement improvement actions, and report compliance to an appropriate oversight committee.

Facility leaders manage panel sizes to ensure patients have timely access to high-quality care.

Executive leaders ensure staff fix or replace damaged furnishings to allow effective cleaning and disinfection.

Executive leaders ensure staff place paper maps at information desks to assist veterans in navigating the facility.

Executive leaders ensure staff store clean equipment in a sanitary environment.

Executive leaders ensure hallways and exits are free from obstruction.

Executive leaders ensure staff remove defective equipment from clinical areas to prevent use.

Executive leaders ensure staff have computer screen privacy filters to protect patients’ personally identifiable information.

Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

The Medical Center Director ensures an environment of care committee meets, as required.

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.

Facility leaders ensure providers who order tests communicate the results to patients timely.

The facility Director ensures staff review primary care panel sizes and capacity levels to ensure they are accurate.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.

The Director ensures the Chief of Staff attends Peer Review Committee meetings.

The Medical Center Director ensures staff store clean and soiled utility items separately, maintain cleanliness, and dispose of expired items.

The Director ensures staff correct deficiencies found during comprehensive environment of care rounds or develop an action plan to address them within 14 business days.

The Director ensures staff conduct fire drills once per shift, per quarter, in each patient area.

Executive leaders ensure staff inspect all medical equipment timely, and equipment has preventive maintenance labels.

Executive leaders ensure staff properly clean patient care areas in the Emergency Department.

Executive leaders ensure staff keep exit pathways free from obstructions.

The Director ensures staff develop service-level workflows for the communication of test results.

The Director ensures staff implement a facility-wide process to monitor providers’ communication of urgent, noncritical test results to patients, and report compliance to an appropriate oversight committee.

Executive leaders ensure staff implement actions from root cause analyses timely, monitor actions for effectiveness and sustained improvement, and report compliance to an appropriate oversight council.

The Director evaluates the patient safety program, including staffing, to ensure executive leaders receive meaningful patient safety information and improvement project data.

Facility leaders implement a standardized process for service-level communication to consistently disseminate information.

Facility leaders ensure Environmental Management Services staff keep patient areas clean and walls intact to minimize the spread of infection.

The Medical Center Director evaluates the allocation of resources to ensure the Housing and Urban Development–Veterans Affairs Supportive Housing program meets the needs of the veterans served.

The OIG recommends facility leaders implement tools to help sensory-impaired veterans navigate the facility.

The OIG recommends facility leaders ensure the facility has a policy for test result communication that includes methods to monitor the effectiveness of the patient notification process.

The OIG recommends facility leaders ensure staff develop workflows for the communication of test results for each service.

The OIG recommends the Director ensures staff have processes to prevent repeat environment of care findings.

The OIG recommends the Veterans Integrated Service Network 1 Director monitors for similar or repeated environment of care findings and ensures facility staff sustain improvements.

The OIG recommends the Veterans Integrated Service Network 1 Director ensures facility leaders identify environment of care trends and establish performance improvement plans with outcome measures to address them.

The OIG recommends the Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present.

The OIG recommends the Director ensures staff keep patient care areas clean and safe.

The OIG recommends the Director ensures only authorized staff have access to medication storage areas.

The OIG recommends the Director ensures staff conduct an inventory of all the facility’s medication storage areas, and the Chief of Pharmacy approves them.

The OIG recommends the Chief of Pharmacy ensures pharmacy staff inspect each approved medication storage area monthly.

The OIG recommends the Director ensures staff monitor temperature and humidity in medication storage areas and track possible deviations, even those that may occur when the areas are closed.

The OIG recommends the Director ensures the Brockton VA Medical Center’s Urgent Care Center operates according to VHA Directive 1101.13 and obtains an appropriate waiver from the VHA National Program Office of Emergency Medicine as applicable.

The OIG recommends facility leaders review the local policy to ensure it complies with VHA directives specific to which staff receive notification of critical test results.

The OIG recommends facility leaders develop and implement a plan to address veterans’ unanswered phone calls.

The OIG recommends the Associate Director ensures staff identify environment of care trends and establish performance improvement plans with outcome measures to address them.

The OIG recommends the Associate Director ensures the manufacturer satisfies contractual requirements to perform preventive maintenance for beds and stretchers and documents the service.

The OIG recommends the Veterans Integrated Service Network Director works with facility and primary care leaders to address the network call center’s effect on primary care team efficiency and workload and reduce the risk of adverse patient safety events.

The OIG recommends the facility Director ensures leaders provide a safe and clean environment of care for veterans, including having adequate staff to clean floors, protecting patient information, and ensuring food is dated and has not expired.

The OIG recommends facility leaders develop and implement a plan to resolve infrastructure issues that affect patient care.

The OIG recommends facility leaders develop and implement a plan to resolve veterans’ unanswered phone calls and inability to reach staff.

The OIG recommends facility leaders replace the emergency call boxes in the parking garage to ensure they are active and functioning.

The OIG recommends facility leaders update local policies and memorandums related to communication of test results.

The OIG recommends the Director ensures the Chief of Staff conducts institutional disclosures for applicable adverse events.

The OIG recommends facility leaders take additional actions to obtain manageable panel sizes per VHA guidelines and ensure patients have access to high-quality care.

The OIG recommends facility leaders evaluate and improve processes for medical clearance of veterans who participate in the Compensated Work Therapy program.

The OIG recommends facility leaders determine appropriate supply storage locations, and for any supplies stored outside these defined locations, implement a process to ensure staff identify and remove expired supplies.

The OIG recommends facility leaders ensure video laryngoscope supplies are readily available and not expired.

The OIG recommends the Director ensures staff keep patient care areas clean and safe.

The OIG recommends the Director ensures staff complete required preventive maintenance for biomedical equipment.

The OIG recommends facility leaders develop service-level workflows and processes to monitor communication of test results to patients.