Recommendations
617
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00104-134 | Comprehensive Healthcare Inspection of the Central Virginia VA Health Care System in Richmond | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations for all Level 3 peer reviews to providers and ensure they implement the improvement actions.
Closure Date:
2 The Chief of Staff ensures the Medical Executive Council documents its review of licensed independent practitioners’ professional practice evaluations and recommend privileges based on the results.
Closure Date:
3 The Executive Director ensures staff store reusable medical equipment in temperature- and humidity-controlled storage locations.
4 The Associate Director ensures staff keep storage rooms and areas used by patients clean and safe.
Closure Date:
5 The Chief of Staff limits medication access to approved staff members.
Closure Date:
6 The Associate Director ensures all toilet rooms within proximity to areas where pelvic examinations are performed, and all women’s, unisex, and family public restrooms have feminine hygiene products available at no cost.
Closure Date:
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| 23-00540-146 | Comprehensive Healthcare Inspection Program and Care in the Community Report: Mammography Services and Breast Cancer Care | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with the National Oncology Program and Veterans Integrated Service Network directors, ensure facility leaders and staff are aware of the services offered to veterans diagnosed with breast cancer through the Women’s Oncology System of Excellence.
Closure Date:
2 The Under Secretary for Health and National Oncology Program staff offer a range of services for patients diagnosed with breast cancer, including rehabilitative services, through the Women’s Oncology System of Excellence.
Closure Date:
3 The Under Secretary for Health, Veterans Integrated Service Network directors, and facility leaders ensure staff enter data into the local cancer registry database in a timely manner.
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| 23-00107-135 | Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs incorporate service-specific criteria in professional practice evaluations.
Closure Date:
2 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00098-151 | Comprehensive Healthcare Inspection of the VA Nebraska-Western Iowa Health Care System in Omaha | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
Closure Date:
2 The Chief of Staff ensures service chiefs document Focused Professional Practice Evaluation results in licensed independent practitioners’ profiles.
Closure Date:
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| 23-01602-147 | Increased Utilization of Primary Care in the Community by the VA Loma Linda Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director confirms that a mechanism is in place to monitor primary care patient aligned care team staffing and panel sizes at the non-VHA-operated clinics to ensure staff are available to care for enrolled patients.
Closure Date:
2 The VA Loma Linda Healthcare System Director directs a review be done of VA Loma Linda Healthcare System adherence to Veterans Health Administration metrics for the processing and scheduling of community care consults and, if not met, determines the reasons for noncompliance, creates an action plan to address deficiencies, and monitors for compliance.
Closure Date:
3 The VA Loma Linda Healthcare System Director conducts an assessment of the community- based outpatient clinic steering committee to ensure consistent oversight of quality of care and staffing levels for all of the VA Loma Linda Healthcare System’s VA outpatient clinics.
Closure Date:
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| 23-00108-149 | Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs document professional practice evaluation results in practitioners’ profiles, and the Medical Executive Committee reviews service chiefs’ recommendations along with clinical competence information when making privileging recommendations to the Director.
Closure Date:
2 The Associate Director ensures staff keep patient care areas safe and clean.
Closure Date:
3 The Director ensures staff regularly test panic alarms in the mental health inpatient unit and document VA police response times.
Closure Date:
4 The Director ensures staff maintain a safe environment in the mental health inpatient unit.
Closure Date:
5 The Director ensures staff maintain a safe environment in the Emergency Department for mental health patients.
Closure Date:
6 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
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| 22-03941-144 | Inspection of Southeast District 2 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
2 The District Director identifies reasons for noncompliance with timely documentation requirements of high-risk client contacts and outcomes in the electronic record and High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.
3 The Readjustment Counseling Service Chief Officer ensures the High Risk Suicide Flag SharePoint site functions as intended and includes accurate data.
Closure Date:
4 The District Director and zone leaders identify reasons for noncompliance, ensure Readjustment Counseling Service policy confidentiality requirements are followed when collaborating care with the support VA medical facility for shared clients at high risk for suicide, and monitor compliance across all zone vet centers.
Closure Date:
5 The District Director identifies reasons for noncompliance with consultation requirements for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures consultation requirements are met; and monitors compliance.
Closure Date:
6 The District Director identifies reasons for noncompliance; ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director identifies reasons for noncompliance, ensures clients are provided a copy of their completed safety plan as required, and monitors compliance across all zone vet centers.
Closure Date:
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| 22-03940-143 | Inspection of Select Vet Centers in Southeast District 2 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, Naples, and San Juan Vet Center Directors, collaborate with the support VA medical facility clinical liaison to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.
Closure Date:
2 District leaders and the Lakeland Vet Center Director, determine reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for at-risk clients, take action to ensure requirements are met, and monitor compliance.
Closure Date:
3 District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of a liaison.
Closure Date:
4 District leaders and the Lakeland Vet Center Director determine reasons for noncompliance and ensure assignment of an external clinical consultant.
Closure Date:
5 District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.
Closure Date:
6 District leaders and the Ft. Lauderdale, Gainesville, and Lakeland Vet Center Directors determine reasons for noncompliance with monthly active counseling records, ensure chart audits are completed as required, and monitor compliance.
Closure Date:
7 District leaders and the Ft. Lauderdale, Ft. Myers, Gainesville, Lakeland, and San Juan Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.
Closure Date:
8 District leaders and the Gainesville and Lakeland Vet Center Directors determine reasons for noncompliance and ensure outreach plans are completed.
Closure Date:
9 District leaders and the Ft Lauderdale, Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.
Closure Date:
10 District leaders and the Ft. Myers, Naples, and San Juan Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.
Closure Date:
11 District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure completion of fire and/or safety inspections, and monitor compliance.
Closure Date:
12 District leaders and the Gainesville Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.
Closure Date:
13 District leaders and the Gainesville and Naples Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are serviced annually, and monitor compliance.
Closure Date:
14 District leaders and the Ft. Lauderdale and Naples Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.
Closure Date:
15 District leaders and the Ft. Myers Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitor compliance.
Closure Date:
16 District leaders, and the Naples Vet Center Director, determine reasons for noncompliance and ensure evacuation plans are posted in a communal area.
Closure Date:
17 District leaders and the Ft. Lauderdale, Ft. Myers, Lakeland, and Naples Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.
Closure Date:
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| 22-03939-142 | Inspection of Select Vet Centers in Southeast District 2 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Marietta, Bay County, and Savannah Vet Center Directors collaborate with the support VA medical facility clinical liaisons to determine the reasons for noncompliance, take action as indicated, and monitor to ensure compliance with staff participation on the mental health executive council.
Closure Date:
2 District leaders and the Marietta and Charleston Vet Center Directors determine reasons for noncompliance, ensure a process is implemented for completing and tracking four hours of external clinical consultation per month, and monitor compliance.
Closure Date:
3 District leaders and the Augusta, Johnson City, Marietta, Charleston, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance, develop processes to ensure all staff complete mandatory trainings, and monitor compliance.
Closure Date:
4 District leaders and the Charleston Vet Center Director determine reasons for noncompliance and ensure outreach plans are completed.
Closure Date:
5 District leaders and the Augusta, Johnson City, Marietta, Bay County, and Savannah Vet Center Directors determine reasons for noncompliance and ensure outreach plans include all required strategic components.
Closure Date:
6 District leaders and the Augusta, Johnson City, and Savanah Vet Center Directors determine reasons for noncompliance, ensure outreach activities are tailored to the cultural demographics of the vet center’s veteran service area, and monitor compliance.
Closure Date:
7 District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure the risk and vulnerability assessment is completed by VA police or local law enforcement, and monitor compliance.
Closure Date:
8 District leaders and the Augusta Vet Center Director determine reasons for noncompliance, ensure fire extinguishers are serviced annually and monitor compliance.
Closure Date:
9 District leaders and the Augusta, Johnson City, Charleston, and Bay County Vet Center Directors determine reasons for noncompliance, ensure fire extinguishers are inspected monthly, and monitor compliance.
Closure Date:
10 The District Director and zone leaders, in conjunction with the Augusta Vet Center Director, determine reasons for noncompliance and ensure vet center obtains an automated external defibrillator.
Closure Date:
11 District leaders and the Charleston Vet Center Director determine reasons for noncompliance, ensure automated external defibrillators are inspected monthly, and monitors compliance.
Closure Date:
12 District leaders and the Charleston and Bay County Vet Center Directors determine reasons for noncompliance, ensure completion of a current and comprehensive emergency and crisis plan, and monitor compliance.
Closure Date:
13 District leaders and the Charleston Vet Center Director determine reasons for noncompliance, and ensures ancillary staff have a desktop reference sheet to address mental health crisis situations.
Closure Date:
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| 23-00118-157 | Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital in Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Veterans Integrated Service Network Director ensures the Veterans Integrated Service Network Chief Medical Officer oversees the hospital’s privileging process.
Closure Date:
2 The Hospital Director ensures staff conduct environment of care inspections in non patient care areas at least once per fiscal year.
Closure Date:
3 The Hospital Director ensures the suicide prevention team conducts a minimum of five outreach activities per month.
Closure Date:
4 The Hospital Director ensures the suicide prevention coordinators report suicide related events monthly to mental health leaders and quality management staff.
Closure Date:
5 The Hospital Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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11259