All Reports

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety between the parking garage and bed tower entrance until completion.

The OIG recommends facility leaders improve doorway safety at the bed tower entrance by placing sensors on the two power-assisted doors, reactivating the revolving door, and monitoring doorway safety until completion.

The OIG recommends the Director ensures staff monitor the emergency exit near the laboratory to make sure the door remains unlocked and operational.

The OIG recommends the Director assesses the facility’s tactile signs (braille) and auditory cues and implements a plan to address the deficient areas.

The OIG recommends facility leaders evaluate the toxic exposure screening process and implement a plan to ensure staff complete the screenings.

The OIG recommends the Director evaluates accessible parking spaces at the circle of the main entrance and ensures access aisles have visible pavement markings and remain available for use.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalks until completion.

The OIG recommends facility leaders improve doorway safety at the main entrance.

The OIG recommends the Director ensures staff have adequate hand hygiene supplies in or near soiled utility rooms that contain biohazardous materials.

The OIG recommends facility leaders ensure the facility policy for communication of test results and service-level workflows comply with VHA requirements, and staff implement processes to monitor patient notification of test results.

The OIG recommends facility leaders increase hiring efforts for the vacant social work positions in the Housing and Urban Development–Veterans Affairs Supportive Housing program, and in the interim, provide staff to support program enrollment.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care oversight councils function according to their charters and meet the required number of times per fiscal year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, reassess community care staffing needs and act as necessary.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility staff import all community care documents into the patient’s electronic health record within five business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment after administratively closing consults that are not low risk.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their community care appointments.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the patient’s electronic health record when they receive medical documentation from the community provider.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.

The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.

The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.

The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.

The OIG recommends that facility leaders review and correct any outdated navigational signage.

The OIG recommends facility leaders define and assign roles and responsibilities to toxic exposure screening navigators and ensure program oversight.

The OIG recommends the Director ensures staff keep patient care areas safe and clean.

The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.

The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.

The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.

The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.

The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.

The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.

Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.

Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that service chiefs responsible for required invasive procedure infrastructure services ensure the completion of the annual review of infrastructure and that existing infrastructure is accurately reported.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures that requirements and processes for invasive procedure complexity infrastructure waiver requests are clearly communicated to facility leaders.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director reviews the process for tracking invasive procedure complexity infrastructure waiver requests, and takes actions as needed to avoid delays in review and submission.

The Under Secretary for Health ensures that guidance provided to Veterans Integrated Service Network and facility leaders regarding the invasive procedure complexity infrastructure waiver request process is clear and consistent with Veterans Health Administration Directive 1220(1).

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director confirms that acute and emergent patient transfer times related to waived infrastructure requirements are tracked and monitored, identifies trends or adverse patient outcomes, and takes actions as warranted.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director directs the chief of surgery, or designee, to attend blood utilization review committee meetings per facility requirements, and ensures compliance.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews the care provided to patient B to confirm compliance with Veterans Health Administration Directive 1004.08, determines if an institutional disclosure is warranted, and takes action as required.

The Under Secretary for Health reviews Veterans Health Administration Directive 1400.01 to confirm that the supervision of PGY-1 surgery residents and guidance provided to Veterans Health Administration facilities aligns with Veterans Health Administration policy and Accreditation Council for Graduate Medical Education program requirements.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that operative documentation is completed per facility policy, reviews the methodology for monitoring operative documentation compliance, and takes action as necessary.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews and monitors staff and health professional trainee compliance with the rules of behavior as it applies to authorized access to all VA computer programs including clinical applications.

The Under Secretary for Health evaluates the process for granting authorized access to VA computer systems for health profession trainees and takes steps to ensure access is provided by the start of trainee rotations at VA facilities.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures the corrective actions developed by facility leaders to address surgical intensive care unit patient safety concerns are completed and evaluated for effectiveness.

The Carl T. Hayden Medical Center Director ensures that supervisory staff take effective actions to correct clinical deficiencies.

The Carl T. Hayden Medical Center Director identifies electronic health records containing the dermatologist’s misuse of copy and paste and takes action as warranted to ensure the safety of patients.

The Carl T. Hayden Medical Center Director ensures that service chiefs and patient safety staff report instances of misuse of copy and paste to Health Information Management System staff.

The Carl T. Hayden Medical Center Director ensures a comprehensive review is conducted to determine if the dermatologist documented electrodesiccation and curettage procedures that were not performed and takes action as warranted, including providing patients with clinical care and disclosures if needed, and notifying the Office of Inspector General.

The Carl T. Hayden Medical Center Director ensures that the Chief of Staff is aware of and addresses pervasive deficiencies, when they exist, in clinical care provided at the facility.

The Desert Pacific Healthcare System Network Director evaluates reasons for noncompliance with the state licensing board reporting policy with regard to the dermatologist, and takes action as needed.

The Carl T. Hayden Medical Center Director ensures that a dermatologist conducts a review of the dermatologist’s patients with consideration of the concerns laid out in this report, to identify patients who may need follow-up care and disclosures, and takes action as warranted.

The Carl T. Hayden Medical Center Director reviews with facility leaders, disclosure requirements outlined in VHA Directive 1004.08, Disclosure of Adverse Events to Patients.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

The Veteran Integrated Service Network Director, in conjunction with facility directors, ensures facility staff scan all community care documents into the patient’s electronic health record within five business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain medical documentation prior to administratively closing consults.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative closure of consults that are not low risk.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within seven days of consult entry or receipt in the department.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended scheduled community care appointments and received care.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per calendar year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff complete the operating model staffing tool reassessment every 90 days.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures VHA staff scan all community care documents into the patient’s electronic health record within five business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff attach diagnostic imaging results to the Community Care Consult Result note.

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative consult closure.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate requests for additional services and supporting medical documentation in patients’ electronic health records.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff verify community care providers’ signatures on requests for additional services forms.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send letters to community providers when they deny requests for additional services.

The OIG recommends facility leaders relocate papers and folders outside of patient examination rooms or secure them in protective coverings to mitigate the risk of infection.

The OIG recommends the Veterans Integrated Service Network Director takes actions to ensure stable and consistent leadership at the facility.

The OIG also recommends Veterans Integrated Service Network leaders assist facility leaders to improve interactions with local union leaders.

The OIG recommends the Interim Medical Center Director ensures all security cameras are operational.

The OIG recommends the Interim Medical Center Director ensures primary care teams are staffed according to Veterans Health Administration guidelines.

The OIG recommends facility leaders ensure staff understand procedures for cleaning equipment and continue to monitor the physical separation of clean and dirty items in storage spaces.

The OIG recommends that primary care leaders incorporate feedback from primary care staff and include them in process improvement projects.

The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.

The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.

The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for improvement and provided guidance on facilities’ action plans to address the deficiencies.

The OIG recommends that Veterans Integrated Service Network leaders ensure facility staff separate clean and dirty equipment and supplies to prevent cross-contamination.

The OIG recommends Veterans Integrated Service Network leaders ensure facility staff keep the environment clean and safe.

The OIG recommends that executive leaders ensure front desk personnel are competent in communicating with sensory-impaired veterans.

The OIG recommends that facility leaders consistently identify opportunities for improvement, ensure staff implement appropriate action plans, and evaluate actions for sustained improvement.

The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.

The OIG recommends facility leaders confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments.

The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.

The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.

The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.

The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.

The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.

The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.

The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.

The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.

The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.

The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.

The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.