All Reports

Date Issued
|
Report Number
23-00107-135
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs incorporate service-specific criteria in professional practice evaluations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00108-149
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff maintain a safe environment in the mental health inpatient unit.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

Date Issued
|
Report Number
22-03941-144
|
Topics:  Mental Health ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance with timely documentation requirements of high-risk client contacts and outcomes in the electronic record and High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer ensures the High Risk Suicide Flag SharePoint site functions as intended and includes accurate data.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director and zone leaders identify reasons for noncompliance, ensure Readjustment Counseling Service policy confidentiality requirements are followed when collaborating care with the support VA medical facility for shared clients at high risk for suicide, and monitor compliance across all zone vet centers.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance with consultation requirements for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures consultation requirements are met; and monitors compliance.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance; ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The District Director identifies reasons for noncompliance, ensures clients are provided a copy of their completed safety plan as required, and monitors compliance across all zone vet centers.

Date Issued
|
Report Number
22-03940-143
|
Topics:  Mental Health ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, Naples, and San Juan Vet Center Directors, collaborate with the support VA medical facility clinical liaison to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Lakeland Vet Center Director, determine reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for at-risk clients, take action to ensure requirements are met, and monitor compliance.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of a liaison.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of an external clinical consultant.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Gainesville, and Lakeland Vet Center Directors determine reasons for noncompliance with monthly active counseling records, ensure chart audits are completed as required, and monitor compliance.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and San Juan Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Gainesville and Lakeland Vet Center Directors determine reasons for noncompliance and ensure outreach plans are completed.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft Lauderdale, Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure completion of fire and/or safety inspections, and monitor compliance.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Gainesville and Naples Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are serviced annually, and monitor compliance.

No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale and Naples Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Myers Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitor compliance.

No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders, and the Naples Vet Center Director, determine reasons for noncompliance and ensure evacuation plans are posted in a communal area.

No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Ft. Lauderdale, Ft. Myers, Lakeland, and Naples Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

Date Issued
|
Report Number
22-03939-142
|
Topics:  Mental Health ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Marietta, Bay County, and Savannah Vet Center Directors collaborate with the support VA medical facility clinical liaisons to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Marietta and Charleston Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Augusta, Johnson City, Marietta, Charleston, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston Vet Center Director determine reasons for noncompliance and ensure outreach plans are completed.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

District leaders and the Augusta, Johnson City, Marietta, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta, Johnson City, and Savanah Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure fire extinguishers are serviced annually and monitor compliance.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Augusta, Johnson City, Charleston, and Bay County Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The District Director and zone leaders, in conjunction with the Augusta Vet Center Director, determine reasons for noncompliance and ensure vet center obtains an automated external defibrillator.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitors compliance.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston and Bay County Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

District leaders and the Charleston Vet Center Director determine reasons for noncompliance, and ensures ancillary staff have a desktop reference sheet to address mental health crisis situations.

Date Issued
|
Report Number
23-00118-157
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Hospital Director ensures the suicide prevention coordinators report suicide related events monthly to mental health leaders and quality management staff.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Hospital Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

Date Issued
|
Report Number
23-00103-138
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff conduct environment of care inspections in patient care areas at least twice per fiscal year.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures Environmental Management Services staff keep areas used by patients clean and orderly.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures all entrances into mental health inpatient units have a sally port.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00116-148
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

Date Issued
|
Report Number
23-00101-137
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff keep patient areas clean and free from undue wear.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
22-04014-130
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures Environmental Management Service staff keep areas used by patients clean and orderly.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff keep furnishings and walls in good repair.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff use solid bottom shelves in storage areas.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff inspect, test, and maintain medical equipment.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.

Date Issued
|
Report Number
23-00013-128
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff conduct environment of care inspections in patient care areas as required.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.

Date Issued
|
Report Number
23-00016-132
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures staff record the Peer Review Committee’s formal discussions related to changes in peer review level assignments in the meeting minutes.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Medical Staff Executive Committee reviews data provided by the Peer Review Committee to determine the need for further action.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations prior to reprivileging to ensure continuous delivery of quality care.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs use specialty-specific criteria in the professional practice evaluations of licensed independent practitioners.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures the Comprehensive Environment of Care Rounds Coordinator or designee schedules environment of care inspections and staff complete and document them at the required frequency.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff test over-the-door alarms based on the manufacturer’s recommendations for mental health inpatient unit sleeping rooms.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff check all mental health inpatient unit ceiling tiles semiannually.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Medical Center Director has sufficient biomedical staff and confirms they inspect and test all medical equipment for scheduled maintenance.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures compliance with VHA Directive 1860, Biomedical Engineering Performance Monitoring and Improvement, for oversight structure of the medical center’s biomedical program.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when clinically appropriate, for all ambulatory care patients.

Date Issued
|
Report Number
22-03013-129
|
Topics:  Care Coordination ● Clinical Care Services Operations ● Mental Health

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health ensures Veterans Health Administration prescribers establish a diagnosis based on a complete and documented assessment prior to initiation of a stimulant to treat attention deficit hyperactivity disorder.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health ensures Veterans Health Administration prescribers assess risks and contraindications associated with stimulant prescribing.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the prescription drug monitoring program query adherence goal for initial stimulant prescribing and takes action as warranted.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the adequacy of the referral processes related to complex mental health disorders, such as attention deficit hyperactivity disorder, and takes action as warranted.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health considers establishing policy and clinical practice guidance related to attention deficit hyperactivity disorder diagnostic assessment and treatment with a stimulant and takes action as warranted.

Date Issued
|
Report Number
22-04112-125
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs define the time frames for Focused Professional Practice Evaluations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation activities

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff remove corrugated containers from patient care areas.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff keep storerooms clean and free of visible dust and soiling.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures Environmental Management Services staff keep patient care areas clean.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures staff remove expired commercial products from patient care areas.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff store clean and dirty equipment separately.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff maintain walls to allow for thorough cleaning.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Associate Director ensures staff test over-the-door alarms in the Inpatient Mental Health unit per the manufacturer’s recommendations.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.

Date Issued
|
Report Number
23-00109-121
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend reprivileging for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation data.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures staff report licensed independent practitioners’ Focused Professional Practice Evaluation results to the Clinical Executive Board.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures the comprehensive environment of care coordinator schedules environment of care inspections at the required frequency and verifies staff complete and document them.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff document police response times to panic alarm testing in the Inpatient Mental Health Unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on Inpatient Mental Health Unit sleeping room doors.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff post hazard warning signs on all access doors where potentially infectious materials are located.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

Date Issued
|
Report Number
23-00111-119
|
Topics:  Mental Health ● Patient Safety ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.

Date Issued
|
Report Number
23-00096-122
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete licensed independent practitioners’ Ongoing Professional Practice Evaluations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation activities.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.

Date Issued
|
Report Number
23-00097-113
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluation data and documents its review prior to recommending licensed independent practitioners’ ongoing privileges to the Director.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures staff complete environment of care inspections at the required frequency.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.

Date Issued
|
Report Number
23-00122-118
|
Topics:  Medical Staff Privileging Credentialing ● Mental Health ● Suicide Prevention
Related Media: Facility Photo

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures medical staff review and document licensed independent practitioners’ Focused Professional Practice Evaluation results and report them to the Medical Executive Board.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by regularly conducting Ongoing Professional Practice Evaluations.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff conduct environment of care inspections in patient care areas at the required frequency.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.