Date Issued
|
Report Number
21-01357-271
|
Topics: Staffing
All Reports
Date Issued
|
Report Number
21-01304-275
|
Topics: COVID-19
● Patient Safety
● Appointment Scheduling and Wait Times
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/31/2025
The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.
Date Issued
|
Report Number
20-01910-244
|
Topics: Contract Integrity
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 10/2/2024
The OIG recommended the executive director of the Office of Acquisition and Logistics assess the warrant justification template and determine whether additional information and guidance should be required.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 10/2/2024
The OIG recommended the executive director of the Office of Acquisition and Logistics determine whether any additional formalized procedures to monitor contracting officer workload should be implemented and required throughout VA.
No. 3
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 10/2/2024
The OIG recommended the executive director of the Office of Acquisition and Logistics identify updates to warrant program policies that can increase the consistency of standards and practices across VA to promote fairness and stringency of warrant requirements.
Date Issued
|
Report Number
21-01334-269
Date Issued
|
Report Number
21-00261-266
|
Topics: Care Coordination
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/9/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee completes a final review of each case within 120 calendar days from the determination that a peer review is needed or approves a written extension request.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/1/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that emergency department and urgent care center staff screen patients for suicide risk using the Columbia-Suicide Severity Rating Scale.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/8/2022
The System Director evaluates and determines any additional reasons for noncompliance and establishes a written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/3/2023
The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate patient transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/24/2024
The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note, that includes all required elements, in the electronic health record prior to patient transfers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/2/2023
The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to the receiving facility during inter-facility transfers.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/24/2024
The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure that nurse-to-nurse communication occurs as part of the inter-facility transfer process.
Date Issued
|
Report Number
21-00269-268
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff consistently attends Surgical Steering Committee meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure the referring provider identifies the receiving physician in the electronic health record.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that referring providers send patients’ active medication lists to receiving facilities.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the assigned prevention and management of disruptive behavior training or required training for transitory, part-time, and intermittent clinical staff.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that members of the Employee Threat Assessment Team complete the required the training.
Date Issued
|
Report Number
21-00257-252
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the acting Systems Redesign and Improvement Coordinator participates on the Quality, Safety, Value Board to review program data and information.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Peer Review Committee submits quarterly summaries of peer review data for review by the Clinical Executive Board.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/10/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and the Chief of Staff attends the meetings.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The System Director evaluates and determines any additional reasons for noncompliance and maintains a current policy to ensure the safe, appropriate, orderly, and timely transfer of patients
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain the Interfacility Transfer Committee monitors and evaluates patient transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/18/2023
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that providers document patients’ informed consent prior to inter-facility transfers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that appropriately privileged providers complete or co-sign the VA Inter-Facility Transfer Form or equivalent note prior to patient transfers.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/1/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that nurse-to-nurse communication between the sending and receiving facility occurs during the inter-facility transfer process.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/10/2022
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification of an Order of Behavioral Restriction, with information regarding the right to appeal, in the Disruptive Behavior Reporting System.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas
Date Issued
|
Report Number
21-00271-258
|
Topics: Suicide Prevention
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The VA Portland Health Care System Director establishes a mental health treatment coordinator policy, consistent with Veterans Health Administration policy, and includes procedures for mental health treatment coordinator assignment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The VA Portland Health Care System Director develops procedures consistent with Veterans Health Administration suicide behavior and overdose report staff-specific guidance and monitors for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Under Secretary for Health aligns policy and training to reflect staff-specific guidance and requirements for suicide behavior and overdose report procedures and disseminates updated information to medical center leaders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The VA Portland Health Care System Director ensures completion of behavioral health autopsy reports within the Veterans Health Administration required time frame.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/24/2022
The Under Secretary for Health clarifies timeframe expectations for notification of Residential Rehabilitation Treatment Programs admission decisions to referring providers and patients, and takes action as warranted.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/2/2022
The VA Palo Alto Health Care System Director ensures that Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration requirements, including screening and admission decision timeliness, communication of treatment recommendations to referring provider and patient, and acceptance of patient self-referrals.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA Palo Alto Health Care System Director makes certain that the VA Palo Alto Health Care System Policy 11K-18-04, Assistance Dog Policy, is consistent with Veterans Health Administration policy.
Date Issued
|
Report Number
20-01802-234
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/19/2023
Coordinate with appropriate officials, including the VA Office of General Counsel, and determine if 38 U.S.C. § 1703(i) and other reimbursement practices cited in this report apply to the reimbursement rates medical facilities should pay for prosthetic and orthotic items provided by vendors. If they do apply, develop and issue guidance requiring medical facilities to adhere to them; if they do not apply, develop and issue guidance on steps medical facilities need to take to ensure they purchase prosthetic and orthotic items at reasonable prices.
No. 2
to Veterans Health Administration (VHA)
Develop and implement effective procedures to monitor prosthetic spending to make sure medical facilities reimburse vendors at reasonable prices for all prosthetic and orthotic items in accordance with updated pricing policies and processes.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/19/2023
Coordinate with appropriate officials such as the Prosthetic and Sensory Aids Service executive director and the executive director, Rehabilitation and Prosthetics Service, to establish a formal oversight structure that defines the roles and responsibilities of those charged with providing oversight of the prosthetics program, rescind handbooks that reflect an outdated oversight structure, and communicate updated oversight expectations to the Veterans Integrated Service Networks to promote consistent program oversight.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/9/2023
Resolve National Prosthetics Patient Database limitations and establish requirements to routinely monitor medical facilities’ input of data to improve accuracy.
Total Monetary Impact of All Recommendations
Open: $ 20,000,000.00
Closed: $ 0.00
Date Issued
|
Report Number
21-02070-265
Date Issued
|
Report Number
21-01509-264
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility staff use standard operating procedures that align with manufacturers’ guidelines when reprocessing colonoscopes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/8/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures Sterile Processing Services chiefs report annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/27/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that Sterile Processing Services chiefs develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures Sterile Processing Services staff properly store high-level disinfected endoscopes.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/8/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/27/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that Sterile Processing Services staff complete competency assessments for reprocessing reusable medical equipment.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that Sterile Processing Services staff receive monthly continuing education.
Date Issued
|
Report Number
21-01677-259
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The Under Secretary for Health clarifies the extent and content of documentation that should be included when circumstances require that a clinical disclosure be entered into the electronic health record.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/15/2022
The Under Secretary for Health evaluates whether there should be a process for clinical provider(s) to communicate back to the Clinical Review Team when changes in patient health status indicate the need for consideration of institutional disclosures, and takes action as warranted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/17/2022
The Veterans Health Care System of the Ozarks Director implements a plan for completion of amended pathology reports for cases identified with level 2 pathology reading errors that is consistent with VHA Handbook 1106.01.
Date Issued
|
Report Number
21-00233-257
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that Veterans Integrated Service Network peer review summary data are collected, analyzed, and acted on, as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Chief Medical Officer determines the reason for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager provides quarterly program updates to Veterans Integrated Service Network leaders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager completes staff education gap assessments related to women’s health and develops educational programs and resources where gaps are identified.
Date Issued
|
Report Number
20-00971-235
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System develop a plan to work with the prime vendor to address having adequate stock from the facility’s formulary list in its warehouse to provide supplies when ordered.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance issues.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System and the director of contracting for South Central VA Health Care Network Contracting Office 16
ensure approving officials and cardholders review their purchases and make sure strategic sourcing is used when it is in the best interest of the government.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System in coordination with the network purchase card program manager, require purchase cardholders to submit ratification requests to the director of contracting for Network Contracting Office 16 for any unauthorized commitments identified.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of contracting for South Central VA Health Care Network Contracting Office 16 ensure quarterly audits of the purchase card program are completed as required by the Veterans Health Administration standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System ensure that the facility meets the Veterans Health Administration’s recommended inventory turnover rate of 12 per year, established by the National Pharmacy Benefits Management program office.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 192,070.00
Date Issued
|
Report Number
21-00245-256
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that all core members consistently attend Surgical Work Group meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that medical center staff monitor and evaluate inter-facility patient transfers.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director determines the reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that the medical center has a current policy for reporting and tracking disruptive behavior.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Disruptive Behavior Committee documents patient notification of an Order of Behavioral Restriction and right to appeal in the Disruptive Behavior Reporting System.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-00044-219
Date Issued
|
Report Number
20-02907-254
|
Topics: Mental Health
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The Tuscaloosa VA Medical Center Director reviews informed treatment consent processes for the Inpatient Mental Health Unit and Community Living Center, confirms staff understanding of required processes, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures decision-making capacity evaluation completion and documentation, as required by Veterans Health Administration policy, and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/14/2022
The Tuscaloosa VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of Alabama commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures adherence to Tuscaloosa VA Medical Center policies regarding against medical advice discharge procedures, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director consults with VA National Center for Ethics in Healthcare and reconsults the Office of General Counsel as needed to evaluate the appropriateness of the patient’s assigned surrogate decision-maker, and takes action as warranted.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Tuscaloosa VA Medical Center Director ensures staff completion of required patient advocate reporting and tracking processes, and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director evaluates the Community Living Center staff’s management of the patient’s correspondence request, including the Integrated Ethics consultation, and takes action as warranted.
Date Issued
|
Report Number
21-00258-230
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/9/2024
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-00262-247
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/15/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Surgical Work Group meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers identify the receiving provider on the VA Inter-Facility Transfer Form or facility-defined equivalent note.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff send the patient’s active medication list to the receiving facility during the inter-facility transfer.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between the sending and receiving facility.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-00263-246
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff document decisions to implement an Order of Behavioral Restriction and patient notifications in the Disruptive Behavior Reporting System.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The System Director evaluates and determines reasons for noncompliance and ensures the chair and members of the Employee Threat Assessment Team complete the required training.