Date Issued
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Report Number
15-04231-223
All Reports
Date Issued
|
Report Number
16-02197-339
Date Issued
|
Report Number
16-01613-326
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/29/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration establishes system-wide requirements for competency assessment and validation, including frequency, for nursing employees who provide post-anesthesia care after operational hours.
Date Issued
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Report Number
15-04248-305
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Malcom Randall VA Medical Center Director develop and implement a quality review process to ensure staff only award purchase orders for modular ramps that are Americans with Disabilities Act compliant and perform follow-up with vendors to ensure installed ramps comply with the Americans with Disabilities Act.
No. 2
to Veterans Health Administration (VHA)
We recommended the Malcom Randall VA Medical Center Director develop a formal plan to identify training needs of staff responsible for purchasing modular ramps and ensure staff are trained periodically and appropriately.
No. 3
to Veterans Health Administration (VHA)
We recommended the Malcom Randall VA Medical Center Director update written procedures to reflect the requirement that staff ensure vendor compliance with Americans with Disabilities Act standards for installed modular ramps.
No. 4
to Veterans Health Administration (VHA)
We recommend the Malcom Randall VA Medical Center Director formally require vendors to provide modular ramp measurements in bid submissions and post-installation photographs.
Date Issued
|
Report Number
13-02255-276
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and issue bills of collection to recover improper payments made to veterans while they were incarcerated.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and take action to make appropriate benefits adjustments and issue bills of collection to recover improper payments for veterans currently incarcerated in Federal penal institutions.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on the Federal incarceration adjustment workload by using monthly data on Federal incarcerations to make appropriate and timely compensation and pension benefits adjustments.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/24/2016
We recommended the Acting Under Secretary for Benefits monitor the terms of the current agreement with the Bureau of Prisons and take timely action to extend the agreement when appropriate.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase the priority placed on state and local incarceration adjustment workload by initiating timely development action after receiving notifications of incarceration from the Social Security Administration.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 9/13/2017
We recommended the Acting Under Secretary for Benefits increase priority of state and local incarceration adjustment workload by making timely incarceration adjustments and issue bills of collection to recover improper payments, as appropriate, after providing due process notification to veterans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 307,900,000.00
Date Issued
|
Report Number
15-01296-203
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/27/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Date Issued
|
Report Number
16-00028-337
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the clinic manager ensures the risk of
infection is minimized when storing and disposing of medical waste at the Childress VA
Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that the clinic manager ensures that exit
routes are unobstructed at the Childress VA Clinic.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that staff at the Childress VA Clinic protect and secure patient-identifiable information.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/31/2016
We recommended that the Childress VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/15/2017
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/15/2017
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that clinicians consistently provide and document interventions for clinically significant abnormal laboratory results.
Date Issued
|
Report Number
15-01887-282
Date Issued
|
Report Number
16-00116-323
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/25/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that facility managers ensure employees follow facility policy for disinfecting exam tables after each patient use and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/23/2016
We recommended that facility managers ensure annual competency assessment for pharmacy employees who prepare compounded sterile products includes a written test and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that the Suicide Prevention Coordinators consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/15/2016
We recommended that nurse managers accurately monitor the nurse staffing methodology implemented in March 2013 and use the standard nursing hours per patient day calculation to assess nurse staffing adequacy for all units.
Date Issued
|
Report Number
15-03867-287
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to improve Emergency Department access and flow during times of increased demand.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to decrease the number of patients who leave the Emergency Department without being seen by a provider.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director review current verbal communication practices in the Emergency Department and determine what steps are reasonable to safeguard patient information.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director assess Emergency Department medication prescription delivery practices to identify potential opportunities to improve pharmacy services.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure all patients in the Radiology Department are supervised.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director assess Environmental Management Services staffing needs and take appropriate actions.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure environment of care concerns identified in this report are corrected and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure Allergy Clinic staff use standard precautions when disposing used thermometer covers and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Phoenix VA Health Care System Director ensure patients receive recommended preventive medications or are offered substitutions if the medication is not on the VA National Formulary.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 11/28/2016
We recommended that the Minneapolis VA Health Care System Director ensure that test results are communicated to patients as required.
Date Issued
|
Report Number
16-01040-324
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/1/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Risk Managers invite clinicians involved in Level 2 or 3 peer reviews to submit comments to and/or appear before the Peer Review Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/25/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers, ensure Facility Directors review all privilege forms annually and document the review.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Medical Staff Coordinators complete the conversion from six-part to two-part credentialing and privileging folders and ensure non-allowed information is not placed in the folders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Chiefs of Surgery discuss surgical deaths with identified problems in Surgical Work Group meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities designate a committee to oversee safe patient handling activities, track patient handling injury data, and share data with safe patient handling champions.
Date Issued
|
Report Number
14-02890-344
Date Issued
|
Report Number
15-03073-275
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken based on the factual circumstances developed in this report regarding appointments incorrectly recorded as canceled by patient.
No. 2
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken regarding instructions to staff to incorrectly record appointments as canceled by patient.
No. 3
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center provides training on when to use clinic versus patient cancellation options and how to identify the clinically indicated appointment date.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/15/2017
We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center improves scheduling audit processes to ensure that managers conduct a complete review of appointment data to ensure scheduling staff are using the correct cancellation type and clinically indicated or preferred appointment date.
No. 5
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center makes sure managers take corrective action when audits identify deficiencies in scheduling staff’s use of appointment cancellation type and clinically indicated or preferred appointment dates.
No. 6
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 16 Director conduct a scheduling audit within 3 months after Recommendations 3 through 5 are implemented to ensure the corrective actions taken were effective.
Date Issued
|
Report Number
15-03700-283
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs rescind and replace Chapters 6 and 7 from Manual 40-2, National Cemeteries, Administration, Operation, and Maintenance.
No. 2
to National Cemetery Administration (NCA)
Closure Date: 1/17/2018
We recommended the Interim Under Secretary for Memorial Affairs recertify or rescind Directive 3170/1, Ceremonies and Special Events at VA National Cemeteries.
No. 3
to National Cemetery Administration (NCA)
Closure Date: 5/14/2018
We recommended the Interim Under Secretary for Memorial Affairs incorporate National Cemetery Administration’s three interim guidance documents into directives or handbooks.
No. 4
to National Cemetery Administration (NCA)
Closure Date: 11/4/2016
We recommended the Interim Under Secretary for Memorial Affairs develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health recertify or rescind Veterans Health Administration’s three religious belief guidance documents that need to be updated.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/12/2017
We recommended the Under Secretary for Health develop mechanisms to ensure staff begin the process of updating guidance and compensate for the time needed to draft guidance and obtain staff concurrence.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/3/2017
We recommended the Under Secretary for Health provide staff a means to request senior official assistance, when necessary, to obtain timely agency-level concurrences.
Date Issued
|
Report Number
16-00118-321
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended that the facility set triggers for when a Focused Professional Practice Evaluation for cause would be indicated.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/7/2016
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that designated employees follow the facility policy for identification of individuals entering the facility after normal business hours and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/29/2016
We recommended that facility managers ensure employees perform and consistently document monthly cleaning of walls and light fixtures in all compounding areas and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/17/2017
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that clinicians include contact numbers of family or friends for support and an assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/27/2017
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
Date Issued
|
Report Number
16-00027-318
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/10/2016
We recommended that the Facility Director ensures that fire drills and fire drill critiques are conducted at least every 12 months at the Winsted VA Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/7/2016
We recommended that the Winsted VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/7/2016
We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
Date Issued
|
Report Number
16-00029-322
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the facility revise the local policy to include specific procedures for the identification of individuals entering the CBOCs.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the facility ensure a safe work
environment with adequate security coverage and incident responses at the Auburn Gresham VA Clinic.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommend that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/5/2017
We recommended that clinicians consistently notify patients of their laboratory results as required by VHA.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/12/2016
We recommended that the facility update its template to ensure providers’ plans of care and disposition are accurately documented for patients with positive PTSD screens.
Date Issued
|
Report Number
16-00121-320
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/7/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/29/2017
We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that employees wear personal protective equipment and gloves when compounding sterile products in the operating room satellite pharmacy and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that sending nurses document transfer assessments and receiving nurses document transfer notes and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that attending physicians co-sign resident physicians’ discharge notes/instructions and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that the facility review and revise its advance directives policy to ensure it is consistent with Veterans Health Administration policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that employees consistently use appropriate note titles to document screening and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that plans include contact numbers of family or friends for support and assessment of available lethal means and how to keep the environment safe and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 4/13/2017
We recommended that clinicians perform and document patient assessments following blood product transfusions and that facility managers monitor compliance.
Date Issued
|
Report Number
14-03183-317
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Community Living Center patients, families, and staff know the circumstances and guidelines under which they should initiate Integrated Ethics consults, have access to the Ethics Consultation Service, and know how to request an ethics consultation.
No. 2
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Community Living Center staff receive training regarding suicide risk factors and the importance of documenting and communicating identified suicide risk factors during Interdisciplinary Team meetings.
No. 3
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that system clinical leadership reviews current practices of the ordering and administration of sleeping medications in the Community Living Center to determine if those practices optimize patient safety.
No. 4
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that reviews of incidents involving patient safety are comprehensive and accurately reflect and document all components as outlined in the VHA National Patient Safety Improvement Handbook guidelines.
Date Issued
|
Report Number
14-04435-265
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/18/2017
We recommended that the Facility Director improve processes for communicating with community-based consumer-run groups that provide mental health services to veterans enrolled at the Knoxville VA Outpatient Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the Facility Director ensure that the Clinic’s Veterans Justice Outreach Specialist provides comprehensive services including outreach for veterans in the Knox and surrounding counties in accordance with Veterans Health Administration policy.