Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00064-172 | Comprehensive Healthcare Inspection of the VA Palo Alto Health Care System in California | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The System Director determines any additional reasons for noncompliance and ensures staff conduct required preventive maintenance on medical equipment.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and ensures only authorized staff have access to medications.
Closure Date:
4 The System Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.
Closure Date:
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| 22-02797-169 | Concerns with Access to Care in the Outpatient Mental Health Clinic at the Charles George VA Medical Center in Asheville, North Carolina | Hotline Healthcare Inspection | ||
1 The Charles George VA Medical Center Director evaluates processes for mental health consult scheduling, including community care referrals, and ensures patients are offered timely appointments, per Veterans Health Administration policies.
2 The Charles George VA Medical Center Director confirms outpatient Mental Health staff receive education about Veterans Health Administration and facility policies related to mental health consult processes, including timeliness and community care consults.
Closure Date:
3 The Charles George VA Medical Center Director evaluates the design, staffing, and implementation of the Behavioral Health Interdisciplinary Program to ensure the program supports timely access to mental health care and takes action as appropriate.
Closure Date:
4 The Charles George VA Medical Center Director confers with Mental Health leaders to identify, track, and mitigate barriers to staff retention and takes appropriate action.
Closure Date:
5 The Charles George VA Medical Center Director ensures Mental Health leaders review current communication practices within Mental Health operations, in accordance with Veterans Health Administration High Reliability Organization values and principles and considers the use of VHA resources, such as the National Center for Organization Development.
Closure Date:
6 The Charles George VA Medical Center Director ensures Mental Health leaders educate Mental Health clinic staff on the role of the suicide prevention team in patient care.
Closure Date:
7 The Charles George VA Medical Center Director reviews and evaluates processes for monitoring and managing Veterans Health Administration-required follow-up care for patients with high risk for suicide patient record flags, including scheduling and tracking of required follow-up appointments, and monitoring compliance.
Closure Date:
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| 22-00231-176 | Comprehensive Healthcare Inspection of the San Francisco VA Health Care System in California | Comprehensive Healthcare Inspection Program | ||
1 The Health Care System Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews, and supervisors ensure implementation of those actions.
Closure Date:
3 The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews Ongoing Professional Practice Evaluation results and documents privileging decisions in the meeting minutes.
Closure Date:
5 The Associate Director for Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures staff check supply rooms for expired supplies and discard them.
Closure Date:
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| 22-00054-158 | Comprehensive Healthcare Inspection of the Southern Arizona VA Health Care System in Tucson | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.
Closure Date:
2 The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete environment of care inspections in patient care areas at the required frequency and document the inspection results.
Closure Date:
3 The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee tracks environment of care inspection deficiencies until they are resolved.
Closure Date:
4 The Director determines any additional reasons for noncompliance and ensures staff post signage in all areas where potentially infectious materials are present.
Closure Date:
5 The Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and furnishings and equipment safe and in good repair.
Closure Date:
6 The Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.
Closure Date:
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| 22-04133-163 | Comprehensive Healthcare Inspection of the VA NY Harbor Healthcare System in New York | Comprehensive Healthcare Inspection Program | ||
1 The Executive Chief of Staff ensures peer reviewers identify at least one aspect of care when assigning a Level 2 or 3 to a peer review.
Closure Date:
2 The Executive Chief of Staff ensures the Peer Review Committee recommends improvement actions to reviewed providers.
Closure Date:
3 The Executive Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations to providers and ensure they implement improvement actions for all Level 2 and 3 peer reviews.
Closure Date:
4 The Executive Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.
Closure Date:
6 The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee monitors environment of care inspection deficiencies until resolution.
Closure Date:
7 The Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on inpatient mental health unit sleeping room doors.
Closure Date:
8 The Deputy Medical Center Director ensures staff post hazard warning signs in all areas where potentially infectious materials are located.
Closure Date:
9 The Deputy Medical Center Director ensures staff keep patient care areas safe and clean.
Closure Date:
10 The Executive Chief of Staff ensures suicide prevention coordinators report suicide-related events to mental health leaders and quality management staff at least monthly
Closure Date:
11 The Executive Chief of Staff ensures designated staff complete a Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.
Closure Date:
12 The Executive Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
Closure Date:
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| 22-01696-160 | Facility Leaders’ Failures in Communications, Construction Oversight, Emergency Preparedness, and Response to an Oxygen Disruption at the West Haven VA Medical Center in Connecticut | Hotline Healthcare Inspection | ||
1 The West Haven VA Medical Center Director ensures communication with patients, families, and staff throughout emergency operations according to the Veterans Health Administration’s Emergency Management Program Guidebook.
Closure Date:
2 The West Haven VA Medical Center Director confirms that medical, nursing, and respiratory therapy staff have the equipment, education, and training to prepare for emergency oxygen procedures.
Closure Date:
3 The West Haven VA Medical Center Director ensures completion of pre-construction risk assessments.
Closure Date:
4 The West Haven VA Medical Center Director ensures patient safety staff participate in facility Construction Safety Committee meetings and activities.
Closure Date:
5 The West Haven VA Medical Center Director evaluates the need for increased oversight of contracted construction companies during high-risk or potential high-risk situations such as construction around underground utilities.
Closure Date:
6 The West Haven VA Medical Center Director ensures annual drills and training to address utility emergencies are completed.
Closure Date:
7 The West Haven VA Medical Center Director confirms that joint patient safety reports are entered for adverse events and close calls and root cause analyses are chartered for high-risk events or potential high-risk events not related to falls, medications, and missing patients.
Closure Date:
8 The West Haven VA Medical Center Director ensures clinical staff document each event of a patient’s care into the health record.
Closure Date:
9 The West Haven VA Medical Center Director ensures that the patient’s episodes of care are reviewed to determine whether a clinical disclosure is needed in accordance with Veterans Health Administration requirements and takes action accordingly.
Closure Date:
10 The West Haven VA Medical Center Director ensures that staff who are designated as a fact finder for a fact-finding investigation receive the needed training and do not have a conflict of interest.
Closure Date:
11 The West Haven VA Medical Center Director determines whether administrative action should be taken with respect to the conduct and performance of the chief of respiratory care.
Closure Date:
12 The Veterans Integrated Service Network Director reviews the content, accuracy, and intent of the Situation, Background, Assessment, Recommendation document and takes administrative action as warranted.
Closure Date:
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| 22-00059-157 | Comprehensive Healthcare Inspection of the VA Central California Health Care System in Fresno | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Chief of Staff evaluates and determines reasons for noncompliance and ensures clinicians complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
Closure Date:
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| 21-03544-111 | Community Care Departments Need Reliable Staffing Data to Help Address Challenges in Recruiting and Retaining Staff | Audit | ||
1 Implement consistent data entry, standardized organizational codes, and periodic reviews for HR Smart community care data.
Closure Date:
2 Develop staffing reports that can be searched by service departments to ensure appropriate resources to meet their assigned missions.
Closure Date:
3 Improve usability of the staffing assessment tool by implementing policy to address the inconsistencies with staffing data entry and review the reported data for accuracy.
4 Assess whether consolidated community care units would more broadly support veterans’ access to community care and help mitigate the impact of staffing shortages, and, if so, develop a project management plan for implementing those units.
Closure Date:
5 Assess the use of monetary and nonmonetary incentives to evaluate whether they are effective in recruiting and retaining administrative staff within community care departments.
Closure Date:
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| 22-04099-153 | Review of VISN 10 and Facility Leaders’ Response to Recommendations from a VHA Office of the Medical Inspector Report, John D. Dingell VA Medical Center in Detroit, Michigan | Hotline Healthcare Inspection | ||
1 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director evaluates and ensures all Veterans Integrated Service Network 10 facilities comply with Veterans Health Administration requirements regarding resident supervision, specifically related to post-graduate year one on-site direct supervision.
2 The John D. Dingell VA Medical Center Director reviews the March 2023 National Surgery Office program review as referenced in the Office of the Medical Inspector report and ensures a comprehensive and sustainable response to the recommendations noted in the National Surgery Office memorandum.
Closure Date:
3 The John D. Dingell VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for National Practitioner Data Bank and State Licensing Board reporting for healthcare providers that meet reporting criteria.
Closure Date:
4 The John D. Dingell VA Medical Center Director ensures the chief of surgery facilitates and provides oversight of morbidity and mortality conferences.
Closure Date:
5 The John D. Dingell VA Medical Center Director ensures that initial level 3 peer review results of Peer Review Committee members’ cases are reassessed by another neutral VA facility Peer Review Committee for final level determination.
Closure Date:
6 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network academic affiliations officer maintains awareness of and performs assigned roles and responsibilities per Veterans Health Administration requirements.
Closure Date:
7 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network surgical workgroup reviews applicable Veterans Health Administration policies, and documents discussion and action plans to reflect facilities’ compliance with Veterans Health Administration policy and surgical complexity level.
Closure Date:
8 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director provides continued oversight and structured support to executive and service line leaders during key leader transitions, and monitors actions taken to ensure completion of action plans.
Closure Date:
9 The John D. Dingell VA Medical Center Director reviews organizational communication channels and ensures consistency with Veterans Health Administration High Reliability Organization goals and considers the use of Veterans Health Administration resources such as the Veterans Health Administration National Center for Organization Development.
Closure Date:
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| 22-04104-112 | Inspection of Information Security at the Northern Arizona VA Healthcare System | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
Closure Date:
2 Ensure vulnerabilities are remediated within established time frames.
3 Implement more effective configuration control processes to ensure network devices maintain vendor support.
Closure Date:
4 Ensure the unmanaged database completes the transition to the VA Enterprise Cloud where it can be managed and have security baselines applied.
Closure Date:
5 Implement an improved inventory process to ensure that all connected devices used to support VA programs and operations are documented in the Enterprise Mission Assurance Support Service.
Closure Date:
6 Ensure network infrastructure equipment is properly installed.
Closure Date:
7 Ensure physical access controls are implemented for communication rooms.
Closure Date:
8 Ensure a video surveillance system is operational and monitored for the data center.
Closure Date:
9 Ensure communication rooms with infrastructure equipment have adequate environmental controls.
Closure Date:
10 Ensure communication rooms with infrastructure equipment have fire-detection and suppression systems.
Closure Date:
11 Ensure water detection sensors are implemented in the data center.
Closure Date:
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15039