All Reports

Comprehensive Healthcare Inspection of the West Texas VA Health Care System, Big Spring, Texas
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19-00034-62
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Topics:  Patient Safety

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 facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that facility leaders review a Patient Safety Annual Report at the end of the fiscal year and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that the Code Blue/Rapid Response Team Committee reviews each resuscitative episode and monitors committee compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the controlled substance coordinator provides the monthly summary of findings and quarterly trends report to the director and monitors the controlled substance coordinator’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the Quality Executive Board reviews the controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substances coordinator performs and documents competency assessments of the controlled substance inspectors annually and monitors controlled substances coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain the controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors the inspectors’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans’ Advisory Committee is comprised of the required core members and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that urgent care center patients are assigned the appropriate stop codes to capture correct patient workload, productivity, and level of service and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that a written provider staffing contingency plan and backup call schedule are maintained for urgent care center providers and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the urgent care center implements the Emergency Department Integration Software tracking program and transmits data to the Emergency Medicine Management Tool and monitors compliance.
Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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19-00012-51
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Topics:  Patient Safety ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures the Executive Committee of the Medical Staff reviews quarterly Peer Review Committee summary reports with trends and analysis of aggregate data and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes sure the patient safety manager includes a review of relevant literature in the root cause analysis and monitors the patient safety manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that clinical managers implement corrective actions and monitor for effectiveness when problems or opportunities for improvement are identified and monitors the clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that clinical service chiefs clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause that do not restrict the providers’ ability to practice independently for more than 30 days with providers and monitors the clinical service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director assures managers remove damaged wheelchairs from service and send them for repair or replacement and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the facility quality manager ensures the Clinical and Performance Board reviews the monthly and quarterly controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses of controlled substances and monitors inspectors’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that a pharmacist reviews the Omnicell® override report for appropriateness and frequency as required and monitors the pharmacist’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
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19-00038-63
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that peer reviewers consistently use at least one of the aspects of care when conducting peer reviews and monitors reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that managers consistently implement, and document completion of improvement actions recommended by the Peer Review Committee and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that peer review data is reported quarterly to the Executive Committee of the Medical Staff and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures utilization management staff complete and document acute inpatient and observations stay reviews as required and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that Physician Utilization Management Advisor(s) consistently complete reviews and document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager or designee completes the required number of root cause analyses that include the required content annually and monitors the patient safety manager’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager or designee provides an annual patient safety report to facility leaders and monitors the patient safety manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinical managers clearly define the criteria, time frames, and expectations with providers in advance for focused professional practice evaluations and monitors the clinical managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Executive Committee of the Medical Staff reviews and evaluates the focused and ongoing professional practice evaluation results and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that patients areas are clean and that action is taken to minimize or eliminate identified safety risks in the environment and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors are appointed in writing with a term not to exceed three years and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that monthly reconciliation of one day’s dispensing from pharmacy to every automated dispensing cabinet and one day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify there is evidence of a written or electronic controlled substances order for five randomly selected dispensing activities during monthly inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided, and monitors clinicians’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians complete and document medication reconciliation as required and monitors the clinicians’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee meets at least quarterly, includes required core members, and reports to the appropriate executive committee and monitors the committee’s compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures tracking and monitoring of cervical cancer data and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the facility has an approved waiver from the national director of Emergency Medicine if the urgent care center continues to operate 24 hours a day, seven days a week.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the urgent care center is staffed with at least two registered nurses physically present during all hours of operation and monitors compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that social work services are available to the urgent care center during all hours of operation, and monitors compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that action plans are developed and implemented for underperforming patient flow metrics in the urgent care center and monitors compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that appropriate signage is in place to direct patients to the urgent care center and monitors compliance.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that at least one room is identified as the psychiatric intervention room in the urgent care center and monitors compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.
Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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19-00043-66
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager completes the minimum requirement of eight root cause analyses each year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the patient safety manager submits each root cause analysis to the National Center for Patient Safety within the required time frame and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that service chiefs clearly define and communicate focused professional practice evaluation criteria in advance with providers and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that ongoing professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that service chiefs clearly define, share, and document in advance the expectations and outcomes for time-limited focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that floors and ceilings tiles are repaired, cleaned, and maintained and window screens are replaced and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures expired medical supplies are removed from supply rooms and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that VA police test panic alarms and evidence of testing is documented and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the comprehensive emergency management plan and its required elements are reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures an emergency operations plan is developed and reviewed annually.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians justify and document the reason for initiating the medication and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians review and reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director requests the required waiver for urgent care clinic operations 24 hours a day, 7 days a week and continues such operations only if the waiver is approved.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that a medical director for the urgent care center is formally appointed.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures the urgent care center has a minimum of two registered nurses on staff during all hours of operation and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that appropriate support services are in place during all hours of UCC operation and monitors compliance.
Review of Staffing and Access Concerns at the Mann-Grandstaff VA Medical Center Spokane, Washington
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19-09017-64
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Mann-Grandstaff VA Medical Center Director takes action to ensure that patients have timely access to care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Mann-Grandstaff VA Medical Center Director ensures continued implementation of corrective actions in response to deficient areas identified in the National Program Office for Sterile Processing report.
Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota
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19-00468-67
|
Topics:  Suicide Prevention ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Minneapolis VA Health Care System Director ensures that Emergency Department staff notify the facility Suicide Prevention Coordinator when a patient presents with suicidal ideation, as required by the Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care, including consults, and considers whether an institutional disclosure is warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Minneapolis VA Health Care System Director ensures that inpatient consult results are acted upon by the responsible provider or appropriate designee and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Minneapolis VA Health Care System Director strengthens processes in root cause analyses consistent with Veterans Health Administration requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures that the Veterans Health Administration establishes written guidance for root cause analysis teams to identify lessons learned and expectations regarding related actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Minneapolis VA Health Care System Director ensures that the Patient Safety Committee and Quality Management Council meeting minutes include deliberations and tracking of actions to resolution, as required by Veterans Health Administration and facility policy.
Comprehensive Healthcare Inspection of the VA Western New York Healthcare System, Buffalo, New York
|
18-04666-55
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that all team members responding to resuscitation events have basic or advanced cardiac life support certification and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that service chiefs include required gastroenterology and pathology specific criteria for those specialties in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that the Executive Committee of the Medical Staff reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director makes certain mental health seclusion room floors are cushioned.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures the required inventory of assets and resources is created and reviewed annually by the Emergency Management Committee and approved by executive leaders and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that staff who conduct monthly review of balance adjustments not be the same staff that perform and document the balance adjustments and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances coordinators maintain necessary records and controlled substance inspectors conduct monthly physical inventory of the controlled substances storage area that are completed on the day initiated and monitors controlled substance coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the pharmacy staff complete the pharmacy inventory checks as required and monitors staff compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the facility has a full-time women veterans program manager and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the Women Veterans Health Committee meets quarterly, is comprised of required core members, reports to executive quadrad leadership with signed minutes, and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the emergency department has a licensed physician privileged to staff the department during all hours of operation and monitors the department’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain the emergency department has the necessary resources readily available to treat sexual assault patients and monitors compliance.
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