All Reports

Pharmacy Process Concerns and Improper Staff Communication at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia
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20-01102-266
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Hunter Holmes McGuire VA Medical Center Director ensures prescriber education on prior authorization drug request consultation procedures including consult documentation options, urgency level communication, patient notification, and appeals processes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director promotes mental health prescribers’ utilization of the prior authorization drug request process in consideration of the medication plan most effective for each patient.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that electronic health records are reviewed for improper entries, and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Hunter Holmes McGuire VA Medical Center Director conducts a review of staff improper electronic health record entries and electronic mail and consults with Office of Human Resources to determine if administrative action is warranted, and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director evaluates ways to improve the workplace relationships between Mental Health and Pharmacy Services staff, including consultation with the Veterans Integrated Services Network or the National Center for Organizational Development, and takes actions as appropriate.
Mismanagement of Emergency Department Care of a Patient with Acute Coronary Syndrome at the Robert J. Dole VA Medical Center in Wichita, Kansas
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20-01318-258
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures that Emergency Department physicians receive training on the facility’s acute coronary syndrome protocol and verifies that ST-elevation myocardial infarction time goals are monitored, and improvements implemented as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director makes certain a facility policy that is applicable to all patient care areas outlines standardized processes for safe and timely interfacility transfers, including communication of appropriate transport services needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director conducts an analysis of the contributing factors that led to the delay in the patient’s interfacility transfer and takes action as necessary to improve identified deficiencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director ensures the newly implemented Emergency Department Interfacility Transfers policy is reviewed and updated to include improvements as data are obtained from the interfacility transfer analysis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director makes certain that Emergency Department and Health Administrative Service staff are trained on the Emergency Department Interfacility Transfers policy, the updated service agreement between Cardiology and Emergency Departments, and interfacility transfer process and monitors the transfer process, including timeliness of transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures the Critical Care Committee evaluates all concerns identified during code events, makes recommendations for improvement, confirms actions are implemented, and assesses effectiveness of actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures the Chief, Quality Management is a member of the Critical Care Committee, develops a process to address problems in obtaining the assistance of Emergency Medical Services or use of the 911 call system, and assesses the effectiveness of the process.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The VA Heartland Network Director reviews the peer reviews of physicians who provided care to the patient to determine if a focused clinical review by an independent reviewer is warranted and takes actions as necessary.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director reviews the patient’s care provided in the Emergency Department and the circumstances of the interfacility transfer to determine if an institutional disclosure is warranted.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2021
The Robert J. Dole VA Medical Center Director ensures interfacility transfer data are collected, analyzed, and incorporated into the Robert J. Dole VA Medical Center’s quality management program as required by Veterans Health Administration policy.
Improved Oversight of Surgical Support Elements Would Enhance Operating Room Efficiency and Care
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18-06039-229
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Topics:  Clinical Care Services Operations ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider developing an oversight mechanism that includes the VISN Surgery Integrated Clinical Community Chair in the monitoring of medical facility operating room efficiency and surgical support element problems and ensures VISN Directors hold medical facilities accountable when these problems persist and reduce operating room efficiency.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider periodically analyzing two to three years of operating room efficiency data to identify medical facilities that have not consistently met National Surgery Office efficiency goals and assess surgical support element problems impacting patients and operating room efficiency.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office clarify the intent of the current utilization measure and assess other utilization measures other than staffing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2020
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office gather as part of its capacity measure information about operating room closures or reduced usage, including the reasons for the closures or curtailment of surgeries.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The OIG recommended the Under Secretary for Health consider identifying surgical support element best practices used by efficient facilities and ensure less efficient medical facilities, where appropriate, implement these practices to address problems, reduce surgical cancellations and delays, and minimize patient risks.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring medical facility surgical work groups to discuss the National Surgery Office Efficiency goals and their facility’s performance with support services, such as logistics, sterile processing service, and environment management service, at least quarterly and ensure they all work proactively and collaboratively to address surgical support element problems.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 30,000,000.00
Date of Receipt of Claims and Mail Processing During the COVID-19 National State of Emergency
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20-02825-242
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/12/2020
Determine what additional actions are needed to make certain that staff understand how to accurately apply the most current guidance to the date of receipt recorded for claims received during the national state of emergency and implement those actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/24/2022
Conduct a review to ensure claims received and completed from March 1, 2020, had the correct date of entitlement applied.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/12/2020
Reevaluate guidance for the date of receipt recorded for claims without a postmark received during the national state of emergency.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 12: VA Great Lakes Health Care System in Westchester, Illinois
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20-00058-250

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director evaluates and determines the reasons for noncompliance and ensures that the Sterile Processing Services Management Board conducts Veterans Integrated Service Network-led facility reusable medical equipment inspections.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are provided to executive leaders.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led reusable medical equipment facility inspection corrective action plans are developed and tracked until closure.
The Veterans Benefits Administration Inadequately Supported Permanent and Total Disability Decisions
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19-00227-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/5/2022
The under secretary for benefits ensures the adjudication procedures manual is updated for consistency with all applicable laws, regulations, and policies related to permanent and total determinations in consultation with the office of general counsel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/2/2022
The under secretary for benefits ensures decision-making staff support their permanent and total status decisions in the Reasons for Decision section of the rating decision by describing the evidence used to support their conclusions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/9/2022
The under secretary for benefits replaces the title and standardized language of “Dependents’ Educational Assistance under 38 U.S.C. Chapter 35” in rating decisions to clearly state that permanent and total status is being considered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2023
The under secretary for benefits ensures appropriate training is provided to decision-making staff based on the changes made to permanent and total procedures related to Recommendations 1, 2 and 3, and monitor the effectiveness of that training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 122,000,000.00
Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery
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20-00131-243
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date a peer review is required, and any necessary extensions are approved in writing by the System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that the Interdisciplinary Peer Review Panel provides quarterly analysis summaries to the Medical Executive Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager includes all required elements in root cause analyses and properly documents root cause analyses in the VHA Patient Safety Information System.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee provides feedback to staff who submit patient adverse event reports that result in root cause analysis actions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete focused and ongoing professional practice evaluations of licensed independent practitioners.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service- or section-specific ongoing professional practice evaluation data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the healthcare system.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that healthcare system managers maintain a safe and clean environment by identifying and resolving environmental deficiencies found during environment of care rounds.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up with patients receiving long-term opioid therapy includes an assessment of intervention effectiveness.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the required time frame for patients flagged as high risk for suicide.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that all required members consistently attend Women Veterans Health Committee meetings and the committee reports to executive leaders.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that healthcare system staff collect and track the required women veterans quality assurance data.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis to the Veteran Integrated Service Network Sterile Processing Services Management Board.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief, Engineering Services conducts annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Reusable Medical Equipment Coordinator completes competency assessments for all staff reprocessing reusable medical equipment.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
Comprehensive Healthcare Inspection of the Birmingham VA Medical Center in Alabama
|
20-00130-241
|
Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Medical Center Director determines the reasons for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that the service chief includes the minimum pathology-specific criteria for focused professional practice evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific criteria for ongoing professional practice evaluations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare practitioner’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that medical center managers keep furnishings and equipment safe and in good repair.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that Environmental Management Services staff separate clean and dirty equipment, devices, and supplies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director evaluates and determines any additional reasons fornoncompliance and ensures that medical center managers maintain safe, functional,and clean patient care areas.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Associate Director evaluates and determines any additional reasons fornoncompliance and ensures that staff secure protected health information withinlaboratory transport containers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of untreated substance abuse, unstable psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans are completed within seven days before or after the High Risk for Suicide Patient Record Flag designation.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans include all required elements for patients with High Risk for Suicide Patient Record Flags.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director for Patient/Nursing Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee
|
19-09493-249
|
Topics:  Suicide Prevention ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director evaluates the current process for patients discharged from the Emergency Department who need to be seen the same day in the Outpatient Mental Health Clinic for medication management, establishes a clear referral process to the Outpatient Mental Health Clinic, and verifies that patients receive the care needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director reviews the Emergency Department Mental Health Handbook and defines a clear process for medication management in the Emergency Department, and ensures that patients receive same day psychiatric medication management when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2022
The Memphis VA Medical Center Director evaluates the current process for Emergency Department physicians to refer patients to the Emergency Department mental health provider for a mental health assessment and verifies that patients who require mental health provider assessment receive the care needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director reviews the current medication reconciliation processes in the Emergency Department and Primary Care Clinics and verifies that providers complete and document medication reconciliation in accordance with policy and makes changes as necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director assesses the Outpatient Mental Health Clinic check-in process and verifies mental health patients are registered, triaged, and receive mental health services as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center ensures that patients are offered the option of community care consult, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director evaluates the outpatient consult process and verifies that providers manage discontinued consults appropriately.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The Memphis VA Medical Center Director evaluates the process for community care clinical oversight, clarifies who has responsibility for coordinating care for patients receiving mental health in the community, and verifies that patients receive authorized community mental health care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2022
The Memphis VA Medical Center Director evaluates the process for timely retrieval of medical records from community care providers, verifies the medical records are uploaded into patients’ electronic health records, and takes action as necessary.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director evaluates the clinical review process for community care authorizations, ensures staff are trained on the process, verifies that authorizations have clinical delegate review, and are processed timely.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director reviews the complaint reporting, responding and tracking processes and ensures that complaints are addressed, resolved, and documented in accordance with current facility policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2021
The Memphis VA Medical Center Director ensures leaders and supervisors are trained on initiating and conducting a fact finding.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2020
The Memphis VA Medical Center Director considers conducting further review to address the differing accounts of the Emergency Department physician and Emergency Department mental health provider regarding the patient referral to ascertain whether the Emergency Department failed to follow facility policy, and takes action if needed.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director ensures that responsible staff receive training on completing behavioral autopsy reports as required by the Veterans Health Administration Behavioral Health Autopsy Program and verifies that behavioral autopsies are completed in accordance with policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director reviews the issue brief reporting requirements with supervisors and ensures timely issue brief reporting for patients who die by suicide.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The Memphis VA Medical Center Director ensures that staff who conduct root cause analyses are trained on the guidelines for interviewing individuals vital to the root cause analysis charter and identified processes, and verifies the root cause analysis interview guidelines are followed.
Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama
|
20-00130-194
|
Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director determines the reason(s) for noncompliance and ensures egresses are free of blockages.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director determines the reason(s) for noncompliance and ensures damaged wheelchairs are repaired or removed from service.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that the Suicide Prevention Coordinator ensures completion and documentation of at least five outreach activities each month.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers document all required elements of goals of care conversations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines reason(s) for noncompliance and certifies that the multidisciplinary committee responsible for life-sustaining treatment decision reviews include three or more different disciplines and at least one member from the medical center’s Ethics Consultation Service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director determines the reason(s) for noncompliance and ensures that the multidisciplinary committee reviews life-sustaining treatment plans for patients who lack decision-making capability and do not have a surrogate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations maintains an accurate file of all reusable devices that includes current manufacturers’ instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and makes certain that the CensiTrac® instrument tracking system is installed and operational.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services areas are cleaned as scheduled.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services staff receive competency assessments for reprocessing reusable medical equipment.
Financial Management Practices Can Be Improved to Promote the Efficient Use of Financial Resources
|
18-03800-232
|
Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2025

The OIG recommended the executive in charge, Office of the Under Secretary for Health, establish financial controls, such as key performance indicators, that align with medical center operations and can be used to assess the efficient use of operating funds.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
Specify the accountable Veterans Health Administration office responsible for establishing financial controls to ensure Veterans Health Administration’s financial management activities promote the efficient use of funds at Veterans Integrated Service Networks.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2021
The OIG recommended the executive in charge, Office of the Under Secretary for Health, require the Veterans Health Administration to establish and publish organizational charts that identify the appropriate financial management reporting lines of authority and to develop familiarization training on the reporting lines of authority at the VISN and medical center levels, as appropriate.
Appointment Management During the COVID-19 Pandemic
|
20-02794-218
|
Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health develop and clearly communicate a well defined strategic plan to all medical facilities for rescheduling patients and provide oversight particularly to those facilities with the highest rates of canceled appointments with no evidence of follow up or tracking.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health develop a mechanism to monitor facilities’ progress with following up on all cancellations to ensure facilities are not solely relying on COVID annotations or cancellation source classifications when rescheduling.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health ensure that facilities take appropriate follow up action on canceled or discontinued consults.
Comprehensive Healthcare Inspection of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois
|
20-00064-238
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures improvement action items recommended by the Quality Council are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain the Patient Flow Committee meeting minutes reflect documentation, implementation, and evaluation of action items.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures service chiefs document focused professional practice evaluation results in provider profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of initially granted privileges.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation criteria.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete licensed independent practitioners’ ongoing professional practice evaluations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the center.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers repair or remove damaged wheelchairs from service.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers maintain a safe and clean environment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures adequate privacy is provided in patient examination rooms at the Evanston VA Clinic.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures the information technology room at the Evanston VA Clinic is secure and restricted to authorized personnel.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Healthcare Center Director determines the reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures that clinicians at community-based outpatient clinics provide integrated mental health services for women veterans.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when clinics have only one provider.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures the Women’s Health Medical Director collects, tracks, and reports quality assurance data.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services aligns standard operating procedures with manufacturers’ guidelines and instructions for use.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services enters all equipment into the CensiTrac® Instrument Tracking System.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff conduct annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Engineering Service or designee conduct and maintain the record of weekly eyewash station function testing.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Associate Director for Facilities Support determines the reasons for noncompliance and makes certain the Environmental Management Supervisor develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are properly stored by Sterile Processing Services and clinical staff.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon
|
20-02240-248
|
Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2021
The Portland VA Health Care System Director ensures that a consistent notification process is implemented and monitored to ensure the sending department notifies the receiving department of a patient’s potential infectious disease status prior to transfer and verifies appropriate infection control precautions are implemented prior to transfer.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2021
The Portland VA Health Care System Director ensures that the standard process for contact tracing for staff exposure to high-consequence infections such as COVID-19 includes a process for identification of potentially exposed staff who cannot be identified through electronic health record documentation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2021
The Portland VA Health Care System Director ensures that standard processes for assessment of staff exposure to high-consequence infections such as COVID-19, including a process for validation of supervisors’ initial risk categorizations, are implemented and monitored to support reliable and accurate exposure risk categorization.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2021
The Portland VA Health Care System Director ensures that standard processes are implemented and monitored for tracking staff exposure, providing guidance on self-monitoring, self-quarantine, and returning to work, and documenting Employee Health Service contacts with exposed employees.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2021
The Portland VA Health Care System Director ensures facility policies are reviewed and updated to include a detailed staff exposure management process to leverage lessons learned from the current pandemic response and to enhance preparedness for future events.
Comprehensive Healthcare Inspection of the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin
|
20-00075-225
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are documented in Quality Management Oversight Committee minutes when problems or opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria in practitioner profiles for focused professional practice evaluations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate, complete, and document the results of focused professional practice evaluations in practitioner profiles.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs consistently collect and review ongoing professional practice evaluation data for the determination to recommend continuation of privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that licensed independent practitioners’ ongoing professional practice evaluations are completed by providers with similar training and privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Medical Executive Committee meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and makes sure that biohazardous rooms are not used to store clean items.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Assistant Director determines the reasons for noncompliance and ensures that clean/sterile storeroom solid-bottom shelves are clean.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center and outpatient clinic buildings.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures that patient care equipment is clean and ready for use.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020

The Medical Center Director ensures that Office of Information Technology leaders determine the reasons for noncompliance and ensures that access is controlled to information technology rooms.

No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment to include a history of substance abuse and psychological disease on all patients prior to initiating long-term opioid therapy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent consistently for patients who are initiating long-term opioid therapy.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within three months and assess adherence to the pain management plan of care and effectiveness of interventions.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the prescribed time frame and include documentation of the patient’s preference for a telephone call, if applicable.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff determines the reasons for noncompliance and ensures that processes and procedures are in place to ensure gynecological care is available 24 hours a day, 7 days per week.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings and report to executive leaders.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that required quality assurance data related to women veterans’ health care services are collected and tracked for improvement opportunities.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020

The Chief of Staff determines the reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.

No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs and documents an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.

No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that the written cleaning schedule for Sterile Processing Services is enforced.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected scopes are stored properly.
Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital in Hines, Illinois
|
20-00069-222
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are monitored and documented in the Quality Board minutes when problems or opportunities are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths within 24 hours of admission are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analyses is reviewed quarterly by the Medical Executive Board.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate and complete focused professional practice evaluations on all newly hired licensed independent practitioners.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum pathology and radiation oncology specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs collect, review, and use ongoing professional practice evaluation data in determinations to continue current privileges.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decisions to recommend initial and continuation of privileges are based on focused and ongoing professional practice evaluation results.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees remove expired commercial sterile supplies from service.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2022
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures clinical areas are in good repair and that a safe and clean environment is maintained throughout the medical center.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers complete pain screening for all patients prior to initial dispensing of long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment on all patients prior to initiating long-term opioid therapy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that follow-up with patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and the effectiveness of the intervention.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that at least 10 percent of reprocessed endoscopes are tested for bioburden.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that traffic flow in the gastroenterology clean storage area is restricted.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff complete Level 1 training within 90 days of hire
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services Chief complete competency assessments for staff reprocessing reusable medical equipment.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Inadequate Inpatient Psychiatry Staffing and Noncompliance with Inpatient Mental Health Levels of Care at the VA Central Western Massachusetts Healthcare System in Leeds
|
19-09669-236
|
Topics:  Mental Health ● Staffing

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The VA Central Western Massachusetts Healthcare System Director ensures adequate psychiatry staffing to afford providers adequate time for direct patient care on the acute and subacute inpatient mental health units.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA Central Western Massachusetts Healthcare System Director provides ongoing monitoring and evaluation of acute and subacute unit medical provider staffing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA Central Western Massachusetts Healthcare System Director ensures that the utilization management plan accurately reflects and is compliant with all Veterans Health Administration requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA Central Western Massachusetts Healthcare System Director makes certain medical officers on duty complete inpatient mental health admission medical clearance assessments in accordance with Central Western Massachusetts Healthcare System and Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The VA Central Western Massachusetts Healthcare System Director makes certain that recovery-oriented programming occurs as scheduled and consists of at least four hours per day.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The VA New England Health Care System Director develops business plans for restructuring of clinical programs to include transitioning sustained treatment and rehabilitation beds, subacute unit beds, and specialized inpatient posttraumatic stress disorder beds as required by the Veterans Health Administration.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The VA Central Western Massachusetts Healthcare System Director consults with Veterans Integrated Service Network 1 leaders to determine and implement a process to monitor clinical appropriateness for patients in all inpatient mental health beds, including sustained treatment and rehabilitation beds until restructuring of clinical programs is complete.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 15: VA Heartland Network in Kansas City, Missouri
|
19-06848-209

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that annual utilization management program summary reviews are completed for each facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact submits an annual Pain Management Strategy implementation and progress report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Network Director determines the reason for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact establishes a pain committee
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director determines the reasons for noncompliance and makes certain that the lead Women Veterans Program Manager executes interdisciplinary strategic planning activities for comprehensive women’s health care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager provides quarterly updates to the Network Director or Chief Medical Officer.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager conducts yearly site visits at each facility within the Veterans Integrated Service Network.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager develops educational programs and/or resources for needs identified from the staff education gap assessment
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager analyzes women veterans’ access and satisfaction data.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager tracks maternity care outcome data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Network Director determines the reasons for noncompliance and ensures that facility corrective action plans are developed and submitted within 30 days of each completed inspection.
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