Recommendations
2132
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00118-157 | Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital in Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.
Closure Date:
2 The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.
Closure Date:
3 The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.
Closure Date:
4 The Hospital Director ensures the suicide prevention coordinators report suicide related events monthly to mental health leaders and quality management staff.
Closure Date:
5 The Hospital Director 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:
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| 23-00094-123 | Comprehensive Healthcare Inspection of the G.V. (Sonny) Montgomery VA Medical Center in Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures the Suicide Prevention Coordinator conducts at least five outreach activities each month.
Closure Date:
| ||||
| 23-00103-138 | Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center in Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.
Closure Date:
2 The Director ensures staff conduct environment of care inspections in patient care areas at least twice per fiscal year.
Closure Date:
3 The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.
Closure Date:
4 The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.
Closure Date:
5 The Associate Director ensures Environmental Management Services staff keep areas used by patients clean and orderly.
Closure Date:
6 The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.
Closure Date:
7 The Director ensures all entrances into mental health inpatient units have a sally port.
Closure Date:
8 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00116-148 | Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit
Closure Date:
2 The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.
Closure Date:
3 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:
4 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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| 23-00024-133 | Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs recommend continuation of current privileges based on Ongoing Professional Practice Evaluation activities
Closure Date:
2 The Director ensures staff keep patient care areas safe and clean.
Closure Date:
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| 23-00012-136 | Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs recommend continued privileges based on Ongoing Professional Practice Evaluation activities
Closure Date:
2 The Chief of Staff ensures the Executive Committee of the Medical Staff/Credentials Committee recommends continuation of licensed independent practitioners’ privileges based on Ongoing Professional Practice Evaluation results.
Closure Date:
3 The Associate Director ensures staff check inventory in clean and sterile storerooms and remove expired or outdated items.
Closure Date:
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| 23-00101-137 | Comprehensive Healthcare Inspection of the VA Bedford Healthcare System in Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Associate Director ensures staff keep patient areas clean and free from undue wear.
Closure Date:
4 The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.
Closure Date:
5 The Director 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:
| ||||
| 22-04014-130 | Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The 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 Associate Director ensures Environmental Management Service staff keep areas used by patients clean and orderly.
Closure Date:
4 The Associate Director ensures staff keep furnishings and walls in good repair.
Closure Date:
5 The Associate Director ensures staff use solid bottom shelves in storage areas.
Closure Date:
6 The Associate Director ensures staff inspect, test, and maintain medical equipment.
Closure Date:
7 The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.
Closure Date:
8 The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.
Closure Date:
| ||||
| 23-00013-128 | Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.
Closure Date:
2 The Director ensures staff conduct environment of care inspections in patient care areas as required.
Closure Date:
3 The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.
Closure Date:
4 The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.
Closure Date:
5 The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.
Closure Date:
6 The Director 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:
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| 22-02398-131 | Veterans Health Administration’s Failure to Properly Identify and Exclude Ineligible Providers from the VA Community Care Program | National Healthcare Review | ||
1 The Under Secretary for Health reviews the criteria and processes used to identify and exclude healthcare providers removed from VA employment for violation of policy related to safe and appropriate care of veterans, and takes action as warranted.
Closure Date:
2 The Under Secretary for Health reviews previous removals of healthcare providers from VA employment as required by VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 § 108 to determine whether the reason(s) for those removals were for violation of policy related to the safe and appropriate care of veterans, and takes action as warranted.
Closure Date:
| ||||
15353