All Reports

Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Cincinnati Education and Research for Veterans Foundation
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18-00711-42
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2020
The Cincinnati Veterans Affairs Medical Center director ensures the Cincinnati Education and Research for Veterans Foundation’s board of directors establishes policies that require responsible officials to verify adequate supporting documentation before approving expenditures.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2020
The Cincinnati Veterans Affairs Medical Center director ensures the Cincinnati Education and Research for Veterans Foundation’s board of directors, or responsible officials, approve reimbursements to the executive director.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The Cincinnati VA Medical Center director establishes procedures to ensure Research and Development Budget Office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with Intergovernmental Personnel Act agreements prior to approving invoices for payment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The Cincinnati VA Medical Center director establishes procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 950,000.00
Improvements Are Needed in the Community Care Consult Process at VISN 8 Facilities
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18-05121-36
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2020
Develop and implement a mechanism for VA facilities and their respective VA community care departments to routinely identify and exchange wait time data to help make decisions that reduce patient wait times.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2020
Routinely monitor the timeliness of each distinct stage of the community care consult process so Veterans Integrated Service Network 8 facilities can identify specific delays.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2020
Ensure facilities routinely monitor the Office of Community Care staffing tool and take appropriate actions to confirm actual staffing levels are sufficient to meet workloads in a timely manner.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
Ensure community care administrative staff are effectively cross-trained to carry out applicable administrative consult processing duties to streamline scheduling and authorizations, and implement a control to monitor whether facilities are processing community care consults in accordance with Office of Community Care guidance and recommendations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
Develop and implement specific facility plans to address the backlog of open consults and the growing number of new consults.
Comprehensive Healthcare Inspection of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
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19-00046-60

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff makes certain that required representatives participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff ensures that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff confirms clinical staff responding to resuscitation events have basic or advanced cardiac life support certification and monitors clinical staff compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff ensures service chiefs include defined time frames in focused professional practice evaluations and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff confirms that service chiefs ensure that focused professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff makes certain service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff confirms that service chiefs ensure that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff makes certain that service chiefs clearly define and share in advance with providers the time frame, expectations, and outcomes for focused professional practice evaluations for cause that do not limit providers’ ability to practice independently for more than 30 days and monitors service chiefs’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff ensures clinicians review and reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The facility director ensures that the facility has a full-time women veterans program manager.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2021
The chief of staff confirms that the Women Veterans Health Committee includes required core members and reports to a clinical executive level committee and monitors the committee’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The chief of staff ensures that program managers implement a process to track and monitor cervical cancer screenings and follow-up care and monitors program managers’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2020
The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The chief of staff ensures the chief of Social Work maintains a backup call schedule for emergency department social workers.
Comprehensive Healthcare Inspection of the West Texas VA Health Care System, Big Spring, Texas
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19-00034-62
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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: 7/9/2020
The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director ensures that facility leaders review a Patient Safety Annual Report at the end of the fiscal year and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The chief of staff ensures that the Code Blue/Rapid Response Team Committee reviews each resuscitative episode and monitors committee compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2020
The facility director ensures that the controlled substance coordinator provides the monthly summary of findings and quarterly trends report to the director and monitors the controlled substance coordinator’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the Quality Executive Board reviews the controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the controlled substances coordinator performs and documents competency assessments of the controlled substance inspectors annually and monitors controlled substances coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The facility director makes certain the controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors the inspectors’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2020
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2021
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The facility director confirms that the Women Veterans’ Advisory Committee is comprised of the required core members and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The facility director ensures that urgent care center patients are assigned the appropriate stop codes to capture correct patient workload, productivity, and level of service and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The chief of staff ensures that a written provider staffing contingency plan and backup call schedule are maintained for urgent care center providers and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The facility director confirms that the urgent care center implements the Emergency Department Integration Software tracking program and transmits data to the Emergency Medicine Management Tool and monitors compliance.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network, Arlington, Texas
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19-06863-69

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The network director makes certain that the quality, safety, and value committee meets at least quarterly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The network director ensures the quality, safety, and value committee analyzes and reviews aggregated quality, safety, and value data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The network director makes certain that the quality management officer collects, analyzes, and acts upon Veterans Integrated Service Network peer review summary data as appropriate and monitors the quality management officer’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The chief medical officer confirms that facility service chiefs clearly define focused professional practice evaluation criteria in advance with licensed independent practitioners and monitors facility service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2021
The chief medical officer confirms that facility service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The network director makes certain that the Veterans Integrated Service Network safety and network emergency management committee sends an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement to leadership for review and approval and monitors the committee’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The quality management officer reviews Veterans Integrated Service Network facilities’ controlled substances inspection quarterly trend reports.
Opportunities Missed to Contain Spending on Sleep Apnea Devices and Improve Veterans’ Outcomes
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19-00021-41
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Topics:  Supplies and Equipment ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2020
Develop a mechanism to assess whether staffing levels within sleep medicine programs are sufficient for monitoring sleep apnea device use and conducting follow-ups with veterans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2022
Ensure the Veterans Health Administration is leveraging existing technologies to make sure medical facilities are routinely monitoring veteran use of sleep apnea devices in a consistent and effective manner to more promptly identify individuals at risk of noncompliance with recommended therapies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2021
Coordinate with the appropriate offices and services, including the Office of Procurement, Acquisitions, and Logistics, Prosthetic and Sensory Aids Service, sleep medicine, and the Veterans Health Administration National Infectious Diseases Service, to (a) assess the viability, potential patient care, and financial impact of an alternative to purchasing sleep apnea devices; (b) make and provide clear guidance on any changes to current Veterans Health Administration processes, including device returns, cleaning, and reissuance; and (c) designate an office with authority to ensure medical facilities implement any processes and recommendations from the assessment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 261,300,000.00
Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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19-00012-51
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Topics:  Patient Safety ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The chief of staff ensures the Executive Committee of the Medical Staff reviews quarterly Peer Review Committee summary reports with trends and analysis of aggregate data and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The facility director makes sure the patient safety manager includes a review of relevant literature in the root cause analysis and monitors the patient safety manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director confirms that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The facility director ensures that clinical managers implement corrective actions and monitor for effectiveness when problems or opportunities for improvement are identified and monitors the clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief of staff confirms that clinical service chiefs clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause that do not restrict the providers’ ability to practice independently for more than 30 days with providers and monitors the clinical service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The associate director assures managers remove damaged wheelchairs from service and send them for repair or replacement and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the facility quality manager ensures the Clinical and Performance Board reviews the monthly and quarterly controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director makes certain that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses of controlled substances and monitors inspectors’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2020
The facility director ensures that a pharmacist reviews the Omnicell® override report for appropriateness and frequency as required and monitors the pharmacist’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2020
The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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19-00043-66
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The facility director makes certain that required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The facility director ensures that the patient safety manager completes the minimum requirement of eight root cause analyses each year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The facility director ensures that the patient safety manager submits each root cause analysis to the National Center for Patient Safety within the required time frame and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The chief of staff ensures that service chiefs clearly define and communicate focused professional practice evaluation criteria in advance with providers and monitors service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The chief of staff ensures that ongoing professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The chief of staff ensures that service chiefs clearly define, share, and document in advance the expectations and outcomes for time-limited focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2021
The associate director ensures that floors and ceilings tiles are repaired, cleaned, and maintained and window screens are replaced and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The associate director ensures expired medical supplies are removed from supply rooms and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The associate director ensures that VA police test panic alarms and evidence of testing is documented and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The facility director ensures that the comprehensive emergency management plan and its required elements are reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2021
The facility director ensures an emergency operations plan is developed and reviewed annually.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020
The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff makes certain that clinicians justify and document the reason for initiating the medication and monitors clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff ensures that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/17/2021
The chief of staff ensures clinicians review and reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The facility director requests the required waiver for urgent care clinic operations 24 hours a day, 7 days a week and continues such operations only if the waiver is approved.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The facility director makes certain that a medical director for the urgent care center is formally appointed.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The chief of staff ensures the urgent care center has a minimum of two registered nurses on staff during all hours of operation and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2021
The chief of staff ensures that appropriate support services are in place during all hours of UCC operation and monitors compliance.
Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
|
19-00038-63
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The chief of staff ensures that peer reviewers consistently use at least one of the aspects of care when conducting peer reviews and monitors reviewers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The chief of staff ensures that managers consistently implement, and document completion of improvement actions recommended by the Peer Review Committee and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2021
The chief of staff ensures that peer review data is reported quarterly to the Executive Committee of the Medical Staff and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures utilization management staff complete and document acute inpatient and observations stay reviews as required and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The facility director ensures that Physician Utilization Management Advisor(s) consistently complete reviews and document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that the patient safety manager or designee completes the required number of root cause analyses that include the required content annually and monitors the patient safety manager’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that the patient safety manager or designee provides an annual patient safety report to facility leaders and monitors the patient safety manager’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that clinical managers clearly define the criteria, time frames, and expectations with providers in advance for focused professional practice evaluations and monitors the clinical managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff makes certain that the Executive Committee of the Medical Staff reviews and evaluates the focused and ongoing professional practice evaluation results and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The associate director ensures that patients areas are clean and that action is taken to minimize or eliminate identified safety risks in the environment and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director ensures that controlled substances inspectors are appointed in writing with a term not to exceed three years and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that monthly reconciliation of one day’s dispensing from pharmacy to every automated dispensing cabinet and one day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that controlled substances inspectors verify there is evidence of a written or electronic controlled substances order for five randomly selected dispensing activities during monthly inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff confirms that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2022
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided, and monitors clinicians’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures clinicians complete and document medication reconciliation as required and monitors the clinicians’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2021
The facility director confirms that the Women Veterans Health Committee meets at least quarterly, includes required core members, and reports to the appropriate executive committee and monitors the committee’s compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The chief of staff ensures tracking and monitoring of cervical cancer data and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain that the facility has an approved waiver from the national director of Emergency Medicine if the urgent care center continues to operate 24 hours a day, seven days a week.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that the urgent care center is staffed with at least two registered nurses physically present during all hours of operation and monitors compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain that social work services are available to the urgent care center during all hours of operation, and monitors compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that action plans are developed and implemented for underperforming patient flow metrics in the urgent care center and monitors compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2020
The facility director makes certain that appropriate signage is in place to direct patients to the urgent care center and monitors compliance.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that at least one room is identified as the psychiatric intervention room in the urgent care center and monitors compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.
Comprehensive Healthcare Inspection of the Canandaigua VA Medical Center, New York
|
19-00037-58

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2020
The associate director makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2020
The associate director makes certain that VA police conduct and document monthly panic alarm testing at the Rochester VA clinic and monitors VA police compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The associate director makes certain that managers maintain a safe environment and ensure furnishings are in good repair at the Rochester VA clinic and monitors managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2020
The associate director ensures that Rochester VA clinic staff secure laboratory transport boxes containing personally identifiable information and monitors clinic staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The facility director ensures that controlled substances program staff consistently reconcile one day’s dispensing from the pharmacy to each automated dispensing unit and monitors controlled substance inspectors’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director makes certain that controlled substances coordinators refrain from conducting routine inspections and monitors coordinators’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director certifies that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2020
The facility director makes certain that the Women Veterans Health Committee includes required core members and that members consistently attend meetings and monitors the committee’s compliance.
Comprehensive Healthcare Inspection of the VA Maryland Health Care System, Baltimore, Maryland
|
19-00016-61
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2021
The facility director ensures that peer reviews are completed within 120 calendar days or that a written extension is requested and approved by the facility director and monitors peer review coordinator’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The chief of staff ensures reporting of peer review data to the Executive Council of the Medical Staff at least quarterly and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The chief of staff ensures that all applicable deaths occurring within 24 hours of admission undergo a peer review and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The facility director ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The facility director ensures the patient safety manager or designee includes all required components in each root cause analysis to ensure quality and consistency of reviews and monitors the patient safety manager’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The facility director ensures the patient safety manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors patient safety manager’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The chief of staff ensures that resuscitative actions performed by staff are in accordance with life-sustaining treatment orders and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The facility director ensures that the Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2021
The chief of staff ensures the service chiefs document the focused professional practice evaluation results in the provider’s profile and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The chief of staff makes certain that the facility’s Executive Committee of the Medical Staff Professional Standards Board reviews all data when recommending continuation of provider privileges and monitors the Committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2021
The chief of staff ensures that service chiefs include reviews of relevant data in professional practice evaluations when determining continuation of provider’s privileges and monitors service chiefs’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2021
The chief of staff ensures the service chiefs include service-specific criteria in professional practice evaluations and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2021
The associate director ensures that areas used by patients are clean and safe and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2022
The associate director confirms that damaged furniture and wheelchairs are repaired or removed from service and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2021
The facility director makes certain that the basement tunnel at Perry Point VA is free from water hazards and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2021
The associate director certifies that panic alarms are installed and tested as required and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The associate director ensures that panic alarms on the locked mental health unit are tested to include VA police response time and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The facility director makes certain that controlled substances inspectors verify controlled substances orders monthly for each medication dispensing cabinet and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The facility director makes certain that monthly reconciliation of one-day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The facility director confirms that controlled substances inspectors complete emergency drug cache inspections, including verification of lock numbers, and monitors inspectors’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The Facility director makes certain that primary care and mental health providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors committee’s compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2021
The facility director ensures that there is a defined process in place and designated staff responsible for tracking and monitoring of cervical cancer screenings as required and monitors compliance.
Comprehensive Healthcare Inspection of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington
|
19-00053-57
|
Topics:  Medical Staff Privileging Credentialing ● Military Sexual Trauma

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2021
The chief of staff ensures that service chiefs initiate and complete focused professional practice evaluations and monitors service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The chief of staff makes certain that service chiefs’ determination to recommend continuation of privileges be based in part on results of ongoing professional practice activities and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The chief of staff ensures that the Clinical Executive Board document its decision to recommend privileges based on focused and ongoing professional practice evaluation results and monitors the board’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The associate director makes certain staff protect patient identification and health information on all computer monitors and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The facility director makes certain monthly panic alarm testing is performed and evidence is maintained at the Lewiston VA Clinic and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The associate director makes certain that the floors and walls are safe and in good condition at the Lewiston VA Clinic and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The associate director ensures that the chief of Facilities Management Service completes and documents weekly emergency generator inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2021
The associate director ensures that the Facilities Management Service chief annually tests all generators requiring an annual supplemental load and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The associate director ensures that the Facilities Management Service chief tests the emergency generators at least once every 36 months for a minimum of continuous four hours and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The facility director ensures that controlled substances inspection staff reconcile one day’s dispensing from the pharmacy to the automated dispensing unit and monitors coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The facility director makes certain that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leaders and monitors coordinator’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The chief of staff ensures providers complete initial evaluations within the required time frame for all new patients referred for mental health services for military sexual trauma and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2021
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The facility director confirms that the Women Veterans Health Committee members attend meetings consistently and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The chief of staff ensures that ordering providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
Review of Staffing and Access Concerns at the Mann-Grandstaff VA Medical Center Spokane, Washington
|
19-09017-64
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Mann-Grandstaff VA Medical Center Director takes action to ensure that patients have timely access to care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2020
The Mann-Grandstaff VA Medical Center Director ensures continued implementation of corrective actions in response to deficient areas identified in the National Program Office for Sterile Processing report.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 4: VA Healthcare, Pittsburgh, Pennsylvania
|
19-06871-59
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2020
The chief medical officer ensures that facilities’ Executive Committees of the Medical Staff document its decision to recommend privileges for licensed independent practitioners based on focused and ongoing professional practice evaluation results and monitors facilities’ committee compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The network director ensures the establishment of a Veterans Integrated Service Network emergency management committee and implementation of all committee requirements.
Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota
|
19-00468-67
|
Topics:  Suicide Prevention ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that Emergency Department staff notify the facility Suicide Prevention Coordinator when a patient presents with suicidal ideation, as required by the Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care, including consults, and considers whether an institutional disclosure is warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that inpatient consult results are acted upon by the responsible provider or appropriate designee and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director strengthens processes in root cause analyses consistent with Veterans Health Administration requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Under Secretary for Health ensures that the Veterans Health Administration establishes written guidance for root cause analysis teams to identify lessons learned and expectations regarding related actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2020
The Minneapolis VA Health Care System Director ensures that the Patient Safety Committee and Quality Management Council meeting minutes include deliberations and tracking of actions to resolution, as required by Veterans Health Administration and facility policy.
Comprehensive Healthcare Inspection of the VA Western New York Healthcare System, Buffalo, New York
|
18-04666-55
|
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: 12/8/2020
The chief of staff confirms that all team members responding to resuscitation events have basic or advanced cardiac life support certification and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The chief of staff ensures that service chiefs include required gastroenterology and pathology specific criteria for those specialties in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The chief of staff ensures that the Executive Committee of the Medical Staff reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director makes certain mental health seclusion room floors are cushioned.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures the required inventory of assets and resources is created and reviewed annually by the Emergency Management Committee and approved by executive leaders and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director ensures that staff who conduct monthly review of balance adjustments not be the same staff that perform and document the balance adjustments and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that controlled substances coordinators maintain necessary records and controlled substance inspectors conduct monthly physical inventory of the controlled substances storage area that are completed on the day initiated and monitors controlled substance coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that the pharmacy staff complete the pharmacy inventory checks as required and monitors staff compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director confirms that the facility has a full-time women veterans program manager and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director makes certain that the Women Veterans Health Committee meets quarterly, is comprised of required core members, reports to executive quadrad leadership with signed minutes, and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The facility director makes certain that the emergency department has a licensed physician privileged to staff the department during all hours of operation and monitors the department’s compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain the emergency department has the necessary resources readily available to treat sexual assault patients and monitors compliance.
Comprehensive Healthcare Inspection of the Louis Stokes Cleveland VA Medical Center, Ohio
|
19-00015-47

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff confirms that clinical managers consistently implement Peer Review Committee’s recommended improvement actions and monitors managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The chief of staff verifies that all applicable deaths within 24 hours of admission are peer reviewed and monitors Peer Review Committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The chief of staff verifies that clinical staff responding to resuscitation events have the required basic or advanced cardiac life support certification and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The associate director for Patient Care Services makes certain that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
The associate director directs the chief of Engineering to ensure the flooring in the locked mental health unit seclusion room provides cushioning and monitors the chief’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2019
The associate director makes certain that directional signage to the emergency department is placed at facility entrances.
Comprehensive Healthcare Inspection of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon
|
19-00052-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures the patient safety manager incorporates all required elements, including consideration of relevant literature and implementation date for action items, into root cause analyses and submits completed analyses to the National Center for Patient Safety within 45 days and monitors the patient safety manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2020
The chief of staff ensures the service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff confirms that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided for newly prescribed medications and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff makes certain that clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff makes certain that ordering providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
Comprehensive Healthcare Inspection of the St. Cloud VA Health Care System, Minnesota
|
19-00055-38

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2020
The chief of staff makes certain that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2020
The chief of staff confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2021
The chief of staff ensures that clinicians provide and document patient/caregiver education and evaluate understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2020
The facility director ensures that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Comprehensive Healthcare Inspection of the Chalmers P. Wylie Ambulatory Care Center, Columbus, Ohio
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19-00051-40

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: 10/8/2020
The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis to ensure quality and consistency of reviews and monitors the patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director ensures that the appropriate committee reviews all resuscitative episodes, to include the required components, and monitors committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures that clinical managers define the focused professional practice evaluation process in advance and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff confirms that clinical managers ensure ongoing professional practice evaluations include service chief’s determination to continue privileges based on the results of the evaluations within the re-privileging period and monitors clinical managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff makes certain that the facility’s Medical Executive Board considers ongoing professional practice evaluation results in its decision to recommend continuation of provider privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain that monthly and quarterly controlled substances inspection reports are reviewed at least on a quarterly basis by the facility committee responsible for quality oversight and that identified corrective actions are followed up until completion and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The chief of staff ensures that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2021
The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2021
The chief of staff ensures that ordering providers notify patients of abnormal results within the required time frame and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The facility director ensures that the chief of staff makes certain that all anesthesia providers follow required steps to ensure consistent and safe handling, storage, and security of controlled substances and monitors compliance.
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