Date Issued
|
Report Number
21-00044-219
All Reports
Date Issued
|
Report Number
20-02907-254
|
Topics: Mental Health
● Patient Safety
Open
Closed-Implemented
Closed-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.
Date Issued
|
Report Number
20-00395-224
|
Topics: Supplies and Equipment
● Purchase Cards
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director account for the disposition of just over $125,000 in unaccounted for supplies in accordance with VA policies.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director determine if any administrative action should be taken on just over $675,000 in unaccounted-for supplies listed in the report of survey.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/28/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure Federal Acquisition Regulation violations that resulted when purchase cards were used to acquire the approximately $1.9 million of supplies are reported to the Financial Services Center, and appropriate remedies, discipline, or penalties are taken in accordance with VA Financial Policy, Volume XVI.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/28/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director request the Veterans Health Administration’s head of contract activity ratify the approximately $1.9 million of identified split purchases.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure appropriate medical center employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain if they are properly using government purchase cards.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure leased operating room equipment is returned to the contractor as soon as possible if there are no plans to use that operating room for at least one year.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,145,291.00
Date Issued
|
Report Number
21-00612-189
Date Issued
|
Report Number
20-03465-243
|
Topics: VA Police
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The under secretary for health makes certain that policies and procedures are developed to require VA police, and other VHA staff as appropriate, to conduct searches for all persons who are reported missing on medical center campuses.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2022
The executive director of the Office of Security and Law Enforcement updates VA Handbook 0730 with revisions clarifying VA police responsibilities with respect to searching for persons who are reported missing on VA property.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The assistant under secretary for health for operations, in consultation with the VA chief security officer, requires VA police chiefs at medical centers to obtain approval from the facility associate director or the medical center director prior to excluding a building or area of the medical center’s campus from regular patrols, and, if the building or area is subject to an enhanced-use lease, confirms with the Office of Enterprise Asset Management and the Office of General Counsel that the exclusion is not in conflict with the terms of the lease.
No. 4
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
For all medical centers that have property subject to enhanced-use leases, the assistant under secretary for health for operations, in consultation with the VA chief security officer, requires the medical center director or the director’s designee to meet with the assigned oversight monitor at the Office of Asset Enterprise Management, the designated local site monitor, and a representative of the Office of General Counsel at least annually—or sooner if there is a change of lease terms or facility leadership—to discuss the terms of the enhanced-use leases and the lessee’s and VA’s responsibilities with respect to the leased properties.
No. 5
to Asset Enterprise Management (OAEM)
Closure Date: 1/28/2022
The executive director of the Office of Asset Enterprise Management includes a copy of the lease and VA Handbook 7454 with the designation memorandum sent to newly appointed lease site monitors.
No. 6
to Asset Enterprise Management (OAEM)
Closure Date: 4/11/2023
The executive director of the Office of Asset Enterprise Management, in conjunction with the Office of General Counsel, reviews all active enhanced-use leases to determine whether any involve portions of buildings also occupied by VA, and, if so, whether they are clear regarding the maintenance and security obligations.
No. 7
to Asset Enterprise Management (OAEM)
Closure Date: 4/11/2023
The executive director of the Office of Asset Enterprise Management modifies its existing Annual Oversight Compliance Certificate policies to include a review of VA’s performance with respect to any services VA is required to provide under the terms of enhanced-use leases.
Date Issued
|
Report Number
21-00260-232
|
Topics: Care Coordination
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024
The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent prior to patient transfer.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024
The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that staff send all pertinent medical records to the receiving facility during inter-facility transfers.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024
The Associate Director Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between the sending and receiving facility.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022
The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024
The Hospital 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.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Hospital Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required training.
Date Issued
|
Report Number
21-02609-229
|
Topics: System Development and Implementation
Date Issued
|
Report Number
21-00251-212
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all sentinel events.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/13/2022
The System Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that required members regularly attend Surgical Work Group meetings.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
4. The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the transferring physician records all required elements on the Inter-Facility Transfer Form or facility-defined equivalent note prior to patient transfers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The Chief of Staff determines the reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that all required members attend Disruptive Behavior Committee meetings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/15/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification for an Order of Behavioral Restriction in the Disruptive Behavior Reporting System.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/25/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete the required training.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
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
20-03938-208
|
Topics: Claims and Appeals
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2021
The OIG recommendated the under secretary for benefits develop and distribute procedures for when the ship locator tool provides results based on deck log coordinates for unlikely locations of herbicide exposure.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2022
The OIG recommended the under secretary for benefits determine and execute additional actions to ensure employees processing Blue Water Navy claims understand how to accurately evaluate and decide herbicide-related medical conditions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 12/27/2021
The OIG recommended the undersecretary for benefits implement a plan for centralized regional offices to conduct local reviews on the accuracy of rating decisions involving herbicide-related medical conditions that will mitigate error trends identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,200,000.00
Date Issued
|
Report Number
21-00253-239
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
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. 2
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete suicide safety plan training prior to developing suicide prevention safety plans.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/26/2022
The System 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 area.
Date Issued
|
Report Number
21-00265-231
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/5/2023
The Associate Director for Patient Care evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Date Issued
|
Report Number
21-00254-213
|
Topics: Care Coordination
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide prevention safety plans.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that inter-facility transfers are monitored and evaluated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff determines the reasons for noncompliance and ensures that appropriately-privileged providers complete or cosign the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to inter-facility patient transfers.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that transferring physicians send active medication lists to receiving facilities during inter-facility transfers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/8/2022
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Date Issued
|
Report Number
20-01917-242
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures that providers receive education regarding the management of alcohol withdrawal and delirium tremens, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director makes certain providers consider patients’ underlying cardiac risk prior to the order of haloperidol.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/13/2022
The Tomah VA Medical Center Director conducts a comprehensive review of the patient’s cardiopulmonary resuscitation event to determine potential causes of failed oxygen delivery including systemic root causes and performance deficiencies, and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted and takes action.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director implements actions recommended by the Out of Operating Room Airway Management workgroup, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director evaluates staff adherence to the Tomah VA Medical Center Policy MS-25, Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Protocol and the Standard Operating Procedure for Nursing Procedure, Symptom Triggered CIWA-Ar Protocol, and takes action to ensure compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/17/2022
The Tomah VA Medical Center Director ensures inpatient medical unit providers and nursing staff compliance with patient restraint management, as required by to the Tomah VA Medical Center Policy, PCS-03, Restraint and Seclusion Use.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director monitors provider compliance with Tomah VA Medical Center Policy MS-06, Admission Criteria for Acute Medicine Unit.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director consults with the Office of General Counsel to ensure the Tomah VA Medical Center Policy PCS-SW-17 Emergency Detention is consistent with Wisconsin law.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director strengthens processes for staff to consider next of kin or family notification in the emergency detention of patients who may not comprehend their legal rights.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures compliance with institutional disclosure procedures, as required by the Veterans Health Administration.
Date Issued
|
Report Number
21-01502-240
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/4/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement action items recommended by the committees responsible for quality, safety, and value oversight functions.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facilities peer review all applicable suicides.
No. 3
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 that root cause analyses include a review of the underlying systems to determine where system redesigns might reduce risk.
No. 4
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 that facilities fully implement approved root cause analysis action items and outcome measures show sustained improvement.
Date Issued
|
Report Number
21-00246-228
|
Topics: Care Coordination
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The System Director evaluates and determines reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator participates on the Quality Safety Values Executive Council.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Staff regularly attends Surgical Work Group meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff complete suicide safety plan training prior to developing suicide safety plans.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The System Director evaluates and determines additional reasons for noncompliance and ensures that all patient transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The System 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 area.
Date Issued
|
Report Number
21-00371-222
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that community health nurses evaluate patients referred for homemaker and/or home health aide services in accordance with Veterans Health Administration policy when determining patient eligibility.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/25/2023
The Fayetteville VA Medical Center Director verifies that interdisciplinary assessments of homemaker and/or home health aide referrals are completed to determine patient eligibility for services.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Fayetteville VA Medical Center Director ensures that community health staff are trained on the eligibility criteria for homemaker and/or home health aide services.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The Fayetteville VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of North Carolina commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that providers consistently assess and document when patients lack decision-making capacity.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures thatproviders consistently determine whether a patient has an identified healthcare agent when patients lack decision-making capacity.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Fayetteville VA Medical Center Director makes certain that patient aligned care team providers and outpatient psychiatrists are educated about initiating specialty care consults for patients.
Date Issued
|
Report Number
20-03359-220
|
Topics: Mental Health
● Community Care
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Under Secretary for Health requires that all community care providers authorized to provide ketamine or esketamine for treatment-resistant depression receive and review VA’s National Protocol Guidance on ketamine infusion and intranasal esketamine.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/25/2022
The Under Secretary for Health evaluates the need for conducting research on the use of ketamine and esketamine for treatment-resistant depression including the comparative efficacy of ketamine and esketamine, the effect of route of administration, therapeutic dose range, mechanism of action, and efficacy and safety of long-term treatment, and initiates research efforts as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director confirms that the facility’s Community Care Service takes timely actions to ensure that administrative processes for care authorization do not disrupt continuity of clinical care.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director makes certain that the facility’s Community Care Service processes incorporate relevant clinical service input in decisions regarding authorization, denial, or discontinuation of care.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director ensures that the facility’s Community Care Service processes incorporate a consistent mechanism for communication with Veterans Health Administration and community clinical providers and patients to facilitate well-timed coordination of care.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The VA San Diego Healthcare System Director monitors implementation of the coordinated, clinically informed plans for continuing care when transitioning the remaining patients from ketamine treatment in the community to care at the facility.