All Reports

The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.

The Executive Director ensures signs are present and accurate throughout the facility.

The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.

The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.

The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.

The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.

The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.

The Director ensures staff keep the environment clean and safe.

The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.

The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.

Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.

The Executive Director ensures staff consistently label reusable medical equipment to show it is clean and ready for use.

Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.

Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.

The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.

Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.

The Director ensures staff keep the environment clean and safe.

Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.

The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.

The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.

The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.

Facility leaders evaluate and improve processes to identify adverse events that warrant an institutional disclosure.

The Director implements processes to ensure staff track action plans until they are completed and report to leaders those that are outstanding.

The Director ensures leaders train staff on their roles and responsibilities when responding to a medical emergency, including the location of equipment used for medical emergencies.

The Director ensures leaders revise the emergency response policy based on recertification time frames in VHA Directive 0999(1) or sooner, if warranted.

Facility leaders ensure all applicable staff maintain basic life support certification and take appropriate action for those staff without it.

The Director ensures facility leaders manage primary care teams’ panel sizes to support patients’ access to care.

The Veterans Integrated Service Network Director develops and implements a plan to provide sustained support and oversight in a constructive manner to the VA Dublin Healthcare System leaders and programs.

The Veterans Integrated Service Network Director ensures that following Veterans Integrated Service Network site reviews with findings, Veterans Integrated Service Network staff review the associated VA Dublin Healthcare System action plans to confirm proposed actions adequately address findings, track action items through implementation, evaluate effectiveness to ensure resolution, and monitor for sustainment.

The Under Secretary for Health considers standardizing the Veterans Integrated Service Network Chief Medical Officer’s and Chief Nursing Officer’s role and responsibilities to include the authority to hold systems leaders accountable for resolving identified deficiencies.

The Associate Medical Center Director ensures Environmental Management Services and nutrition staff maintain clean patient food storage areas.

The Associate Medical Center Director ensures staff monitor storage areas and remove expired supplies.

The Associate Medical Center Director ensures Environmental Management Services staff make feminine hygiene products available in public women’s and unisex restrooms.

The Chief of Staff ensures staff establish written service-level workflows for the communication of test results.

Facility leaders ensure staff have access to sinks or hand hygiene supplies in or near soiled utility rooms that store biohazardous materials.

Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.

Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.

Executive leaders ensure staff post safety risk assessment permits for all construction projects.

The Director assigns a member of the executive leadership team as chair of the Construction Safety Committee to oversee safety activities.

Executive leaders ensure staff install privacy curtains in all exam rooms.

Executive leaders ensure staff install handrails on both sides of the hallway in the Community Living Center.

Executive leaders ensure staff follow the facility’s policy for communication of abnormal test results to patients.

The Associate Director for Operations ensures staff keep patient care areas clean and clean storage areas free of dirty items and equipment.

The Chief of Staff ensures the facility has workflows for all services to identify team members’ roles in the test result communication process.

The Executive Director ensures each service has a service-level workflow for test result communication.

The Executive Director reviews current practices to obtain documents from community providers and determines if leaders can standardize an approach to improve timeliness.

The Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.

The Associate Director ensures staff make feminine hygiene products available in public women’s and unisex restrooms.

The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.

Biomedical staff indicate inspection dates on all equipment.

The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.

The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers’ recommendations.

The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.

The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.

The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.

Facility leaders ensure staff perform preventive maintenance in accordance with manufacturers’ guidelines and clearly define staff responsibilities.

Executive leaders continue to recruit a permanent chief of biomedical engineering and implement processes to prevent repeat environment of care findings.

The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patient’s care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.

The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessment’s administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses’ adherence; and conducts audits to ensure improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients’ on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.

The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.

The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administration’s nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.

The VA Greater Los Angeles Healthcare System Director confirms that facility staff made reasonable efforts to conduct an institutional disclosure with the patient’s family.

Executive leaders ensure staff fix or replace damaged furnishings to allow effective cleaning and disinfection.

Executive leaders ensure staff place paper maps at information desks to assist veterans in navigating the facility.

Executive leaders ensure staff store clean equipment in a sanitary environment.

Executive leaders ensure hallways and exits are free from obstruction.

Executive leaders ensure staff remove defective equipment from clinical areas to prevent use.

Executive leaders ensure staff have computer screen privacy filters to protect patients’ personally identifiable information.

Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.