All Reports

Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.

The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops workflows for all services that communicate test results to patients and includes the process for assigning designees (surrogates) for providers who order tests in the facility’s policy, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop workflows that describe how each team member participates in the process for communicating test results.

The Central Virginia VA Health Care System Director evaluates inpatient mental health unit discharge practices and develops processes to assess a caregiver’s capability to ensure a safe discharge.

The Central Virginia VA Health Care System Director ensures complaints to the patient advocate are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.

The Central Virginia VA Health Care System Director ensures medication reconciliation is completed at discharge and during post-discharge encounters according to Veterans Health Administration Directive 1345, Medication Reconciliation.

The Central Virginia VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1199, Reporting Cases of Abuse and Neglect, requirements related to clinical staff escalating encounters involving potential abuse and neglect.

The Central Virginia VA Health Care System Director conducts a comprehensive review of the patient’s hospitalization and post-discharge encounters and takes action as indicated, including quality management improvement processes.

The Under Secretary for Health considers establishing a process, to be used on non‑business days, that enables Veterans Crisis Line responders to timely escalate concerns of non‑imminent abuse to a mandated reporter.

Facility leaders implement measures to keep all eyewash stations clean and safe for emergency use.

Facility leaders implement measures to keep walkways free of obstructions to maintain clear exit routes.

The Director updates the facility’s written policy for test result communications to comply with requirements in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director of Patient Care Services/Nurse Executive develop and implement written workflows for each service that comply with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Medical Center Director develops service-level workflows for communicating test results.

The Medical Center Director monitors data on the communication of test results to providers and patients as required by VHA Directive 1088(1), Communicating Test Results to Providers and Patients.

The VA Portland Health Care System Director ensures the Community Reintegration Services director and Health Care for Homeless Veterans program coordinator establish a process to monitor and verify case managers comply with monthly veteran contacts as required by the facility’s HCHV Case Management Workflow Guide, and takes action as warranted.

The VA Portland Health Care System Director ensures Health Care for Homeless Veterans staff discharge veterans from the Health Care for Homeless Veterans program in accordance with the facility’s HCHV Case Management Workflow Guide.

The VA Portland Health Care System Director reviews the quality management evaluations, once completed, for Veteran A’s and Veteran B’s care, and takes action as warranted.

The VA Portland Health Care System Director evaluates the Community Reintegration Services reporting structure and resources to determine if the current structure allows for effective oversight of essential homeless programs, and makes modifications if needed.

The VA Portland Health Care System Director ensures the Community Reintegration Services director monitors and verifies Grant and Per Diem liaisons’ compliance with Veterans Health Administration Directive 1162.01 requirements related to conducting veteran contacts.

Facility leaders ensure staff follow procedures to properly separate and store soiled and clean equipment.

Facility leaders ensure environmental management services staff clean ice machines daily to help prevent infection risk.

Facility leaders ensure staff properly label and store oxygen tanks.

Facility leaders ensure staff update the facility policy to include all elements to communicate test results to patients, as required in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

Executive leaders ensure staff maintain a clean and safe environment.

The Medical Center Director ensures providers complete secondary toxic exposure screenings within 30 days.

The Chief of Staff ensures facility leaders develop workflows for all services to identify team members’ roles in the process for communicating test results.

The Martinsburg VA Medical Center Director conducts a comprehensive review of the peer review process from identification to completion to ensure adherence with Veterans Health Administration Directive 1190(1), Peer Review for Quality Management, amended July 19, 2024, and takes action as warranted.

The Martinsburg VA Medical Center Director ensures the chief of surgery assesses Surgeon B’s alleged disruptive behavior and takes action if needed, in accordance with VA Handbook 5021, Employee-Management Relations, and Martinsburg VA Medical Center bylaws.

The Under Secretary for Health reviews the Veterans Health Administration’s current use of generative AI chat tools, defines permissible clinical uses for general-purpose AI chat tools, oversight responsibilities, and risk mitigation, and outlines a plan for implementation.

The Under Secretary for Health evaluates whether safeguards applied to other high-impact AI tools, such as Ambient AI Scribe, should be adapted for generative AI chat tools used for clinical care and documentation.

The Under Secretary for Health oversees integration of AI-related risk monitoring into existing patient safety programs and ensures staff are trained to identify and report AI-related safety events.

The Veterans Integrated Service Network Director conducts a comprehensive review of the care provided to the patient prior to the event, and takes action as indicated.

The Robley Rex VA Medical Center Director ensures that the facility has a mechanism in place for how Veterans Health Administration healthcare professionals will provide content of suicide prevention safety plans when completing suicide prevention safety plans with patients over the phone.

The Robley Rex VA Medical Center Director reviews facility Primary Care-Mental Health Integration guidance documents and ensures consistency and alignment with Veterans Health Administration requirements.

The Robley Rex VA Medical Center Director reconsiders the practice of reauthoring notes in the Computerized Patient Record System by behavioral health technicians in the Primary Care-Mental Health Integration call center, identifies other facility areas that use the reauthoring process, and takes action as indicated.

The Under Secretary for Health evaluates ways to mitigate the implications resulting from users’ ability to change authors in an unsigned note in the Computerized Patient Record System to ensure that such practice is limited to those in roles with a need to have that function, and takes action as indicated.

The Robley Rex VA Medical Center Director ensures that root cause analyses are completed in accordance with Veterans Health Administration policy, including root cause analysis process steps, timeliness, and team roles.

The Robley Rex VA Medical Center Director ensures that patient safety managers receive oversight, training, and support as required by the Veterans Health Administration.

The Robley Rex VA Medical Center Director ensures that the chief of quality understands the seriousness and implications of altering documentation without support, and that leaders, whose actions contributed to the deficiencies outlined in this report, receive administrative action, as appropriate.