Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-04112-125 | Comprehensive Healthcare Inspection of the VA Northern Indiana Health Care System in Marion | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs define the time frames for Focused Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation activities
Closure Date:
3 The Director ensures staff remove corrugated containers from patient care areas.
Closure Date:
4 The Director ensures staff keep storerooms clean and free of visible dust and soiling.
Closure Date:
5 The Director ensures Environmental Management Services staff keep patient care areas clean.
Closure Date:
6 The Associate Director for Patient Care Services ensures staff remove expired commercial products from patient care areas.
Closure Date:
7 The Director ensures staff store clean and dirty equipment separately.
Closure Date:
8 The Director ensures staff maintain walls to allow for thorough cleaning.
Closure Date:
9 The Associate Director ensures staff test over-the-door alarms in the Inpatient Mental Health unit per the manufacturer’s recommendations.
Closure Date:
10 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 23-00109-121 | Comprehensive Healthcare Inspection of the VA Maine Healthcare System in Augusta | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures leaders identify and evaluate sentinel events and conduct and document institutional disclosures when criteria are met.
Closure Date:
2 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.
Closure Date:
3 The Chief of Staff ensures service chiefs recommend reprivileging for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation data.
Closure Date:
4 The Chief of Staff ensures staff report licensed independent practitioners’ Focused Professional Practice Evaluation results to the Clinical Executive Board.
Closure Date:
5 The Veterans Integrated Service Network Chief Medical Officer provides effective oversight of credentialing and privileging processes at the healthcare system.
Closure Date:
6 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.
Closure Date:
7 The Medical Center Director ensures staff document police response times to panic alarm testing in the Inpatient Mental Health Unit.
Closure Date:
8 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.
Closure Date:
9 The Medical Center Director ensures staff maintain a safe environment in the Inpatient Mental Health Unit.
Closure Date:
10 The Medical Center Director ensures staff post hazard warning signs on all access doors where potentially infectious materials are located.
Closure Date:
11 The Medical Center Director ensures staff keep patient care areas safe and clean.
12 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.
Closure Date:
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| 23-00111-119 | Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff identify sentinel events and take appropriate action when home oxygen fires occur.
Closure Date:
2 The Veterans Integrated Service Network Director ensures network staff track and monitor home oxygen vendor completion of root cause analyses when sentinel events occur.
Closure Date:
3 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.
Closure Date:
| ||||
| 23-00096-122 | Comprehensive Healthcare Inspection of the VA Central Iowa Health Care System in Des Moines | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation activities.
Closure Date:
3 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.
Closure Date:
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| 23-00967-64 | Veteran Readiness and Employment Staff Improperly Sent Participants to Veteran Employment Through Technology Education Courses | Review | ||
1 Develop and implement policies and system controls to ensure all programs approved for use by vocational rehabilitation counselors for Veteran Readiness and Employment participants meet the requirements of applicable laws and regulations
Closure Date:
2 Train all appropriate Veteran Readiness and Employment regional office staff on manual requirement to verify the programs are approved for use before selecting participants and to verify facility codes match from authorization through enrollment.
Closure Date:
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| 23-00097-113 | Comprehensive Healthcare Inspection of the VA Black Hills Health Care System in Fort Meade, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.
Closure Date:
2 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.
Closure Date:
3 The Director ensures staff complete environment of care inspections at the required frequency.
Closure Date:
4 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.
Closure Date:
| ||||
| 23-00122-118 | Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming | Comprehensive Healthcare Inspection Program | ||
1 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.
Closure Date:
2 The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by regularly conducting Ongoing Professional Practice Evaluations.
Closure Date:
3 The Medical Center Director ensures staff conduct environment of care inspections in patient care areas at the required frequency.
Closure Date:
4 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly.
Closure Date:
5 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 22-03164-106 | Comprehensive Healthcare Inspection of the VA Ann Arbor Healthcare System in Michigan | Comprehensive Healthcare Inspection Program | ||
1 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 all ambulatory care settings.
Closure Date:
| ||||
| 22-03167-110 | Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-01450-114 | Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.
Closure Date:
2 The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.
Closure Date:
3 The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.
Closure Date:
4 The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.
Closure Date:
5 The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.
Closure Date:
6 The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.
Closure Date:
7 The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.
Closure Date:
8 The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites
Closure Date:
9 The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.
Closure Date:
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15039