Recommendations
2222
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 26-00053-273 | Healthcare Facility Inspection of the VA NY Harbor Healthcare System in New York | Healthcare Facility Inspection | ||
1 The Medical Center Director takes appropriate action so emergency department and dental clinic staff maintain a clean and safe environment and repair or replace damaged items to support effective disinfection, as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.
2 The Medical Center Director takes appropriate action so emergency department staff establish and maintain an environment that protects patients’ privacy, as required by the Joint Commission standard, Rights and Responsibilities of the Individual 01.01.01.
3 The Medical Center Director takes appropriate action so all services develop workflows in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients, including defining responsibilities of non-provider personnel for communicating test results to patients.
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| 26-00084-274 | Healthcare Facility Inspection of the VA White River Junction Healthcare System in Vermont | Healthcare Facility Inspection | ||
1 The Director installs detectable warning surfaces at all walkways that transition to roadways, in accordance with VA’s PG-18-10, Site Design Manual.
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| 25-03943-269 | Mental Health Inspection of the South Texas Veterans Health Care System in San Antonio | Mental Health Inspection Program | ||
1 The Associate Chief of Staff, Mental Health develops and implements written processes to ensure treatment planning on the inpatient mental health unit aligns with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service requirements.
2 The Associate Chief of Staff, Mental Health requires a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit, in alignment with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.
3 The Facility Director ensures implementation of a recovery-oriented environment on the inpatient mental health unit, consistent with Veterans Health Administration’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.
4 The Facility Director develops and implements a written standard operating procedure for the use of video monitoring on the inpatient mental health unit, as required by Veterans Health Administration Office of Mental Health Standard Operating Procedure 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06.”
5 The Chief of Staff ensures that only healthcare staff have access to video monitoring in treatment areas and that video equipment is used for monitoring, not recording, in accordance with Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.
6 The Facility Director posts signage to notify veterans of video monitoring on the inpatient mental health unit, as required Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.
Closure Date:
7 The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements in Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.
8 The Chief of Staff requires documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administrationand develops a plan to monitor for sustained compliance, in accordance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures.
9 The Chief of Staff ensures discharge instructions include appointment locations in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”
Closure Date:
10 The Facility Director requires all Interdisciplinary Safety Inspection Team members attend biannual inspections and record attendance consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.
11 The Facility Director directs the Interdisciplinary Safety Inspection Team to provide biannual inspection attendance to the Comprehensive Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.
12 The Facility Director ensures staff complete appeals within the required time frame in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.1, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Inspections and Appeals Under VHA [Veterans Health Administration] Directive 1167.”
13 The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.
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| 25-04267-174 | Inspection of Information Security at the Lovell Federal Healthcare System in Illinois | Information Security Inspection | ||
1 Improve vulnerability management processes so that all vulnerabilities are identified and mitigated; for vulnerabilities that cannot be mitigated by VA deadlines, create plans of action and milestones.
Closure Date:
2 Improve the baseline configuration process to make sure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.
3 Confirm appropriate network isolation and protections for all medical devices and special‑purpose systems hosted on the Lovell Federal Healthcare System networks.
4 Separate the duties of maintaining physical blank key stock and making keys to improve physical access controls over key inventories.
Closure Date:
5 Improve the process for monitoring and servicing uninterruptible power supplies that support the network infrastructure.
6 Complete the installation of grounding measures for all communications closets.
7 Establish a process to make sure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.
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| 24-03185-148 | Review of Minor Construction and Nonrecurring Maintenance Projects at the Fayetteville VA Medical Center in Arkansas | Review | ||
1 In collaboration with the director of Veterans Integrated Service Network 16, verify engineering staff are complying with Veterans Health Administration policies and guidance associated with architectural and engineering design review and inspection procedures.
Closure Date:
2 Verify that all engineering staff understand and are trained on VA design and physical security requirements related to minor and nonrecurring maintenance construction projects.
3 Verify that engineering staff who develop independent government cost estimates are sufficiently trained on developing a statement of work and how these documents affect the cost estimates.
4 Ensure engineering staff are documenting their review and acceptance of architectural and engineering designs as required by the Federal Acquisition Regulation before the solicitation of construction contracts.
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| 26-00030-213 | Healthcare Facility Inspection of the Salisbury VA Health Care System in North Carolina | Healthcare Facility Inspection | ||
1 The Director takes appropriate actions to maintain a clean environment to reduce the risk of infection, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.
2 The Director takes appropriate actions so staff change privacy curtains to reduce the risk of infection and supervisors monitor compliance, in accordance with the facility’s Infection Prevention and Control Manual.
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| 26-00038-262 | Healthcare Facility Inspection of the VA Tuscaloosa Healthcare System in Alabama | Healthcare Facility Inspection | ||
1
The Director takes appropriate action so staff properly store cleaning supplies and leaders monitor corrective actions for sustained compliance, in accordance with Veterans Health Administration Directive 1131, Management of Infectious Diseases and Infection Prevention and Control Programs.
2 The Director takes appropriate action so staff update the facility policy for communicating test results and develop service-level workflows that describe team members’ roles in the process, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
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| 25-00255-206 | Healthcare Facility Inspection of the VA Philadelphia Healthcare System in Pennsylvania | Healthcare Facility Inspection | ||
1 The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.
2 The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.
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| 25-03939-259 | Mental Health Inspection of the VA Kansas City Healthcare System in Missouri | Mental Health Inspection Program | ||
1 The Facility Director develops and implements clearly defined written processes for providing mental health care to veterans on medical units.
2 The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements.
3 The Chief of Staff ensures documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.
4 The Chief of Staff ensures veterans’ discharge instructions include the appointment location in easy-to-understand language.
5 The Chief of Staff ensures discharge instructions are free of medical abbreviations and includes the purpose for each listed medication and develops a plan to monitor for sustained compliance.
Closure Date:
6 The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the acute inpatient mental health unit and develops a plan to monitor for sustained compliance.
7 The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including attendance at environment of care inspections, record of required members’ attendance at inspections in meeting minutes, and develops a plan to monitor for sustained compliance.
8 The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training.
Closure Date:
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| 25-03937-260 | Mental Health Inspection of the VA Jackson Healthcare System in Mississippi | Mental Health Inspection Program | ||
1 The Healthcare System Director ensures the Mental Health Executive Council includes ongoing veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.
2 The Associate Chief of Service, Mental Health ensures the local recovery coordinator serves in a full-time capacity, in accordance with Veterans Health Administration requirements Directive 1163, Psychosocial Rehabilitation and Recovery Services.
3 The Healthcare System Director ensures the physical environment on the inpatient mental health unit reflects recovery-oriented principles according to Veterans Affairs’ Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.
4 The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures requirements related to documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration, and develops a plan to monitor for sustained compliance.
5 The Chief of Staff ensures veterans’ discharge instructions include the follow-up mental health appointment location information in easy-to-understand language, in accordance with Veterans Health Administration’s “Clinic Profile Management Business Rules,” and develops a plan to monitor for sustained compliance.
6 The Chief of Staff ensures discharge instructions include the purpose for each listed medication, consistent with Veterans Health Administration Directive 1345, Medication Reconciliation, and develops a plan to monitor for sustained compliance.
7 The Chief of Staff ensures staff provide a copy of the suicide prevention safety plan to veterans upon discharge from the inpatient unit, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.
8 The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to record and report attendance of inspections to the Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.
9 The Healthcare System Director develops and implements a plan to monitor Mental Health Environment of Care Checklist training completion for sustained compliance, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.
10 The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion attestation is accurately documented, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA [Veterans Health Administration] Directive 1167,” and develops a plan to monitor for sustained compliance.
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