All Reports

Inadequate Inpatient Psychiatry Staffing and Noncompliance with Inpatient Mental Health Levels of Care at the VA Central Western Massachusetts Healthcare System in Leeds
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19-09669-236
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Topics:  Mental Health ● Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The VA Central Western Massachusetts Healthcare System Director ensures adequate psychiatry staffing to afford providers adequate time for direct patient care on the acute and subacute inpatient mental health units.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA Central Western Massachusetts Healthcare System Director provides ongoing monitoring and evaluation of acute and subacute unit medical provider staffing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA Central Western Massachusetts Healthcare System Director ensures that the utilization management plan accurately reflects and is compliant with all Veterans Health Administration requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA Central Western Massachusetts Healthcare System Director makes certain medical officers on duty complete inpatient mental health admission medical clearance assessments in accordance with Central Western Massachusetts Healthcare System and Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The VA Central Western Massachusetts Healthcare System Director makes certain that recovery-oriented programming occurs as scheduled and consists of at least four hours per day.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA New England Health Care System Director develops business plans for restructuring of clinical programs to include transitioning sustained treatment and rehabilitation beds, subacute unit beds, and specialized inpatient posttraumatic stress disorder beds as required by the Veterans Health Administration.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The VA Central Western Massachusetts Healthcare System Director consults with Veterans Integrated Service Network 1 leaders to determine and implement a process to monitor clinical appropriateness for patients in all inpatient mental health beds, including sustained treatment and rehabilitation beds until restructuring of clinical programs is complete.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 15: VA Heartland Network in Kansas City, Missouri
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19-06848-209

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that annual utilization management program summary reviews are completed for each facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact submits an annual Pain Management Strategy implementation and progress report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Network Director determines the reason for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact establishes a pain committee
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director determines the reasons for noncompliance and makes certain that the lead Women Veterans Program Manager executes interdisciplinary strategic planning activities for comprehensive women’s health care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager provides quarterly updates to the Network Director or Chief Medical Officer.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager conducts yearly site visits at each facility within the Veterans Integrated Service Network.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager develops educational programs and/or resources for needs identified from the staff education gap assessment
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager analyzes women veterans’ access and satisfaction data.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager tracks maternity care outcome data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director determines the reasons for noncompliance and ensures that facility corrective action plans are developed and submitted within 30 days of each completed inspection.
Comprehensive Healthcare Inspection of the Robert J. Dole VA Medical Center in Wichita, Kansas
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19-06872-199
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analysis actions are implemented and properly documented in the VHA Patient Safety Information System.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that the Patient Safety Manager or designee provides an annual patient safety report to medical center leaders.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers consistently collect and review ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Professional Standards Board meeting minutes consistently reflect the review of professional practice evaluation results when recommending continuation of privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff determines reason(s) for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines reason(s) for noncompliance and ensures the departing licensed healthcare professional’s first- or second-line supervisor appropriately signs the exit review form.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director determines reason(s) for noncompliance and ensures that patient care supply areas are properly designated, and adequate temperature and humidity controls are continuously monitored and maintained.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics to the medical center.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame and document the patient’s preference for telephonic follow-up, if warranted.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete safety plans in a timely manner and that all required elements—including firearm and opioid safety—are assessed for patients with High Risk for Suicide Patient Record Flags.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures clinical and nonclinical staff receive annual suicide prevention refresher training.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and appoints a multidisciplinary committee responsible for life-sustaining treatment decision reviews that includes representatives from three or more different disciplines.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that Sterile Processing Services reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services maintain required airflow parameters for areas where reusable medical equipment is reprocessed.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that staff avoid eating, drinking, and/or storing food items in areas where decontamination, sterilization, or clean/sterile storage occurs.148
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services determines reason(s) for noncompliance and ensures that staff properly store endoscopes.
Site Visit Program Can Do More to Improve Nationwide Claims Processing
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19-07062-230
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Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2020
The OIG recommended that the under secretary for benefits direct the Compensation Service to formalize the Hot Topics list into an annual report submitted to the Office of Field Operations detailing all recurring deficiencies and action items identified throughout the inspection year from its site visit program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2021
The OIG recommended that the under secretary for benefits require the Office of Field Operations to initiate a recurring plan to correct all recurring deficiencies and action items identified by the Compensation Service throughout the inspection year from its site visit program annual report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2021
The OIG recommended that the under secretary for benefits direct the Office of Field Operations to establish a follow-up process to monitor compliance with the new requirement and hold regional office managers accountable for making corrections and addressing action items in a timely manner.
Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center in Chicago, Illinois
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20-00077-211
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Topics:  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: 1/15/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a minimum of 80 percent of inpatient utilization management reviews are completed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The 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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that the Medical Executive Council documents conclusions and recommendations for continuation of privileges that are based on focused professional practice evaluation results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2022
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 providers’ departure from the medical center.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that service leaders immediately report a provider’s failure to meet generally accepted standards of practice to state licensing boards
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians 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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that clinicians document justification for concurrent opioid and benzodiazepine medication therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians 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: 8/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians 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: 1/15/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider follow-up with patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Chief of Staff determines the reasons for noncompliance and ensures that mental health providers consistently contact or attempt to contact high-risk patients who miss mental health or substance abuse appointments and properly document those efforts.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that providers complete safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Chief of Staff evaluate and determines any additional reason for noncompliance and makes certain that suicide prevention safety plans include all required elements.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2021
The Medical Center 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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2022
The Medical Center Director determines the reasons for noncompliance and makes certain that a multidisciplinary life-sustaining treatment decisions committee is established to review all proposed plans.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each site of care has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend the Women Veterans Health Committee meetings.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/18/2021
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. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
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. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2022
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Comprehensive Healthcare Inspection of the VA St. Louis Health Care System in Missouri
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19-06873-210
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Topics:  Medical Staff Privileging Credentialing ● Suicide Prevention ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures improvement actions recommended by the Quality Executive Board are fully implemented and improvement changes are monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee consistently implements improvement actions arising from root cause analysis activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2023
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.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2021
The Associate Director determines the reasons for noncompliance and ensures mental health unit cameras are reconfigured to eliminate blind spots.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
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 beginning long-term opioid therapy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
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 and assess intervention effectiveness.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Pain Committee monitors the quality of pain assessment, effectiveness of pain management interventions, and opportunities for improvements.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator delivers at least five outreach activities each month.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
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 consent, within the required time frame.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings and that the committee reports to an executive leadership board.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that gastroenterology staff test at least 10 percent of reprocessed endoscopes for bioburden and testing to include each endoscope model.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
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.
Improving VA and Select Community Care Health Information Exchanges
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20-01129-220

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2021

The Under Secretary for Health reviews the barriers related to the utilization of VA Direct and ensures the Veterans Health Information Exchange Program Office increases the number of facilities using VA Direct as a secure option to share health information.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office evaluates the VA Exchange and VA Direct training and education programs and increases accessibility to Veterans Health Administration staff, community partners, and veterans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office increases the number of community partners, including more state exchanges and other Health Information Exchange stakeholders, to facilitate the expansion of bidirectional health information exchange.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2021
The Under Secretary for Health confirms the Veterans Health Information Exchange Program Office evaluates the performance work statements of the Veterans Health Information Exchange community coordinators and ensures compliance with the scope of work.
Surrogate Decision-Maker, Clinical, and Patient Rights Deficiencies at the Robley Rex VA Medical Center in Louisville, Kentucky
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19-08666-212
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Robley Rex VA Medical Center Director ensures staff document clinical assessments of patients’ decision-making capacity throughout hospitalization as required by Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Robley Rex VA Medical Center Director evaluates social worker practices related to facilitating the release of information when a patient lacks decision-making capacity, and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Robley Rex VA Medical Center Director establishes “reasonable inquiry” parameters for determination of a surrogate as required by Veterans Health Administration policy and provides staff education as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Robley Rex VA Medical Center Director ensures that when patients lack decision-making capacity, staff verify and document the status of surrogates, and the efforts to identify surrogates, according to Veterans Health Administration policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director evaluates the quality and comprehensiveness of clinical documentation in support of diagnoses and treatment decisions across the patient’s hospitalization, and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director ensures interdisciplinary and cross-service communication and collaboration for complex patients and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2021
The Robley Rex VA Medical Center Director ensures providers complete medication reconciliation for patients transferred to the mental health unit(s) as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director ensures compliance regarding completion of documentation of PRN (as needed) medication effectiveness as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2021
The Robley Rex VA Medical Center Director reviews clinical decision-making and administrative processes relative to the patient’s admission to hospice, and takes appropriate actions as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2021
The Robley Rex VA Medical Center Director develops a mechanism to ensure involuntary admissions (72-hour holds) for current and future patients are managed and documented according to Veterans Health Administration and Robley Rex VA Medical Center policies, and Kentucky state laws.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director develops a mechanism to ensure that patients in behavioral restraints are assessed every 15 minutes as required, and that documentation complies with Veterans Health Administration policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director ensures that its policy on restraints and seclusion is updated to reflect the frequency of training requirements, and that staff are appropriately trained and competent in the use of restraints as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2021
The Robley Rex VA Medical Center Director takes action to ensure processes for reviewing inpatient deaths is consistent with Veterans Health Administration policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director reviews the patient’s continuum of care and evaluates if additional peer reviews and/or other quality reviews are warranted, and takes action as indicated.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Robley Rex VA Medical Center Director reviews the circumstances related to an unauthorized individual making decisions for the patient and conducts appropriate disclosure to the patient’s representative as warranted.
Accuracy of Disability Benefit Evaluations for Veterans' Service-Connected Heart Diseases
|
19-08095-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/5/2020
We recommended the under secretary for benefits implement a plan to incorporate the system-generated instructions for medical providers directly into the heart disability questionnaire (instead of separately on the examination request) and determine whether additional revisions are necessary to ensure medical providers’ findings are sufficient for evaluation purposes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/13/2021
We recommended the under secretary for benefits implement a plan to ensure medical providers who complete heart disability benefits questionnaires are made aware of common problem areas related to the questionnaire format and system-generated instructions and are provided guidance on how to avoid giving conflicting or insufficient information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/13/2021
We recommended the under secretary for benefits implement a plan to make certain that Veterans Benefits Administration decision makers receive refresher training on identifying and resolving heart disability benefits questionnaires that are insufficient for evaluation purposes and monitor the effectiveness of the training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 61,800,000.00
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.
Alleged Deficiencies in Pharmacy Service Procedures at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia
|
19-09776-223
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The Louis A. Johnson VA Medical Center Director ensures implementation of a process to document and track orientation, competency assessment, and annual competencies of pharmacy staff, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The Louis A. Johnson VA Medical Center Director ensures facility leaders are trained in the process of reporting any and all future diversions and loss incidents according to requirements outlined in VHA Directive 1108.01, Controlled Substance Management, May 1, 2019.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The Louis A. Johnson VA Medical Center Director conducts a review of the circumstances that resulted in the misplacement of testosterone and develops an action plan to prevent a similar recurrence, if warranted.
Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois
|
20-00062-205
|
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.
Facility Oversight and Leaders’ Responses Related to the Deficient Practice of a Pathologist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia
|
19-07600-215
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that the Pathology and Laboratory Medicine Services actionable supplemental test results are communicated timely in accordance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that facility leaders adhere to Veterans Health Administration policy that outlines the processes for the disclosure of adverse events, including clinical and institutional disclosures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Hunter Holmes McGuire VA Medical Center Director reviews the treatment course for the identified dermatology patient who experienced an adverse clinical outcome and takes action, including disclosures, if appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting of all adverse events to the patient safety manager.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting adverse events to the VA Pathology Regional Commissioner.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to issue briefs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that facility leaders adhere to Veterans Health Administration policy that outlines the summary suspension process for licensed independent practitioners.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Hunter Holmes McGuire VA Medical Center Director verifies that facility leaders adhere to Veterans Health Administration policy that outlines the credentialing and privileging process as related to the subject pathologist.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The Hunter Holmes McGuire VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for state licensing board reporting.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/27/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that the Pathology and Laboratory Medicine Service Chief ensures the required Veterans Health Administration and facility quality reviews of the Pathology and Laboratory Medicine Services’ pathologists are performed.
Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center
|
19-07507-214
|
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.
Allegations of Nepotism at the Miami VA Healthcare System in Florida
|
18-01781-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2020
The Miami VA Health Care System Director determines the appropriate administrative action to take, if any, with respect to the chief nurse’s advocacy in favor of hiring the spouse.
Alleged Misuse of Official Time and Possible Ethics Violation by an Information Technology Employee
|
17-04969-202

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/26/2021
The employee’s supervisor confers with the Designated Agency Ethics Official and the Office of Human Resources and Administration to determine the appropriate administrative action to take, if any, with respect to the employee’s conduct in connection with the procurement of hotel services from the employer of the spouse.
Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri
|
19-06850-208
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
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 providers’ profiles.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results. 
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
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 departing the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nursing staff label multidose medication vials with an expiration date upon opening.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that privacy curtains are installed in all examination rooms at the Shawnee VA Clinic.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures a record of visitor access for the information technology room is maintained at the Shawnee VA Clinic.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete a behavior risk assessment that includes a history of substance abuse, mental health problems or disorders, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy. 
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent prior to initiating patients on long-term opioid therapy. 
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians follow up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions. 
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff receive annual suicide prevention refresher training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a multidisciplinary life-sustaining treatment decisions committee is established to review all proposed plans. 
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
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 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: 7/23/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that airflow is monitored in the gastroenterology clinic clean scope rooms.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that damaged flooring or tiles are repaired or replaced in the gastroenterology clean scope storage room.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected endoscopes are stored properly.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
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.
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