Recommendations
638
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00094-123 | Comprehensive Healthcare Inspection of the G.V. (Sonny) Montgomery VA Medical Center in Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures the Suicide Prevention Coordinator conducts at least five outreach activities each month.
Closure Date:
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| 23-00103-138 | Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center in Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the Peer Review Committee recommends improvement actions for all peer reviews.
Closure Date:
2 The Director ensures staff conduct environment of care inspections in patient care areas at least twice per fiscal year.
Closure Date:
3 The Associate Director ensures staff maintain all medical equipment in accordance with manufacturers’ recommendations or use an alternative maintenance program that does not reduce the safety of the equipment.
Closure Date:
4 The Chief of Staff ensures medications transported by the pneumatic tube system are only accessible by approved individuals.
Closure Date:
5 The Associate Director ensures Environmental Management Services staff keep areas used by patients clean and orderly.
Closure Date:
6 The Director ensures staff check over-the-door alarms in mental health inpatient units with corridor doors to patient sleeping rooms according to the manufacturer’s guidelines.
Closure Date:
7 The Director ensures all entrances into mental health inpatient units have a sally port.
Closure Date:
8 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00116-148 | Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff document VA police response times to panic alarm testing in the Inpatient Psychiatry Unit
Closure Date:
2 The Medical Center Director ensures staff follow the manufacturer’s guidelines for checking over-the-door alarms for patient sleeping rooms in the Inpatient Psychiatry Unit.
Closure Date:
3 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly
Closure Date:
4 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 23-00024-133 | Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs recommend continuation of current privileges based on Ongoing Professional Practice Evaluation activities
Closure Date:
2 The Director ensures staff keep patient care areas safe and clean.
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| 23-00012-136 | Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs recommend continued privileges based on Ongoing Professional Practice Evaluation activities
Closure Date:
2 The Chief of Staff ensures the Executive Committee of the Medical Staff/Credentials Committee recommends continuation of licensed independent practitioners’ privileges based on Ongoing Professional Practice Evaluation results.
Closure Date:
3 The Associate Director ensures staff check inventory in clean and sterile storerooms and remove expired or outdated items.
Closure Date:
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| 23-00101-137 | Comprehensive Healthcare Inspection of the VA Bedford Healthcare System in Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Director ensures staff complete a root cause analysis for all events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Associate Director ensures staff keep patient areas clean and free from undue wear.
Closure Date:
4 The Director ensures staff check over-the-door alarms on the mental health inpatient unit according to the manufacturer’s guidelines.
Closure Date:
5 The Director 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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| 22-04014-130 | Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Associate Director ensures Environmental Management Service staff keep areas used by patients clean and orderly.
Closure Date:
4 The Associate Director ensures staff keep furnishings and walls in good repair.
Closure Date:
5 The Associate Director ensures staff use solid bottom shelves in storage areas.
Closure Date:
6 The Associate Director ensures staff inspect, test, and maintain medical equipment.
Closure Date:
7 The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.
Closure Date:
8 The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.
Closure Date:
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| 23-00013-128 | Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs report Focused Professional Practice Evaluation results to an executive committee of the medical staff for consideration in privileging recommendations.
2 The Director ensures staff conduct environment of care inspections in patient care areas as required.
Closure Date:
3 The Director ensures staff test panic alarms in the Inpatient Psychiatry Unit at least quarterly and record testing in a log, including police response times.
Closure Date:
4 The Director ensures staff test over-the-door alarms in the Inpatient Psychiatry Unit per the manufacturer’s recommendations.
Closure Date:
5 The Director ensures staff keep interior spaces in the Inpatient Psychiatry Unit safe and suitable for care.
6 The 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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| 22-02398-131 | Veterans Health Administration’s Failure to Properly Identify and Exclude Ineligible Providers from the VA Community Care Program | National Healthcare Review | ||
1 The Under Secretary for Health reviews the criteria and processes used to identify and exclude healthcare providers removed from VA employment for violation of policy related to safe and appropriate care of veterans, and takes action as warranted.
2 The Under Secretary for Health reviews previous removals of healthcare providers from VA employment as required by VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 § 108 to determine whether the reason(s) for those removals were for violation of policy related to the safe and appropriate care of veterans, and takes action as warranted.
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| 23-00876-74 | Improved Oversight Needed to Evaluate Network Adequacy and Contractor Performance | Audit | ||
1 Holds future third-party administrators accountable for operational readiness and provider network adequacy at each facility by the time the contracts are implemented.
Closure Date:
2 Develops a process to make sure the third-party administrators regularly update their Community Care Network provider lists to reflect accurate provider contact information and annotate providers who are not currently accepting VA patients.
Closure Date:
3 Develops a mechanism for facilities to effectively report, track, and monitor challenges with access to specialty care services; trains all relevant staff on how to use the mechanism; make sure facilities use the mechanism routinely; and then helps facilities resolve access challenges.
Closure Date:
4 Develops and communicates to facilities a standard process to request and document their needs for additional providers.
Closure Date:
5 Evaluates the effectiveness of the third-party administrators’ quarterly and monthly reports for assessing network adequacy and then, if needed, modifies the language in its current contracts and makes changes to the applicable contract language for future Community Care Network contracts.
Closure Date:
6 Develops its own network adequacy performance reports for each facility and communicates the results to the facilities monthly.
Closure Date:
7 Conducts Advanced Medical Cost Management Solution training for community care staff at each facility on evaluating network adequacy through the tool.
Closure Date:
8 Routinely evaluates the third-party administrator’s network adequacy performance reports to ensure the reports are sufficiently reliable and comply with contract requirements, and then holds third-party administrators accountable for resolving identified issues.
Closure Date:
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11259