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Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

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OIG Reports

| 22-00234-200 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ reprivileging recommendations are based, in part, on Ongoing Professional Practice Evaluation activities.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee considers professional practice evaluation results in decisions to recommend privileges.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures staff complete Comprehensive Suicide Risk Evaluations.

| 22-00055-184 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for Level 3 peer reviews.

No. 2   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines reasons for noncompliance and ensures section or service chiefs define time frames for Focused Professional Practice Evaluations.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff determines the reasons for noncompliance and ensures service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures Medical Executive Council meeting minutes consistently contain its recommendations for privileging requests

No. 6   to Veterans Health Administration (VHA)

The Associate Director, Operations evaluates and determines any additional reasons for noncompliance and ensures staff inspect, test, and maintain all medical equipment.

No. 7   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain equipment and furnishings in good working order and keep areas used by patients clean, safe, and suitable for care.

No. 8   to Veterans Health Administration (VHA)

The Director evaluates and determines reasons for noncompliance and ensures that only breathable shower curtains are present in mental health inpatient unit bathrooms.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff or Associate Director, Patient Care Service/Nurse Executive determines the reasons for noncompliance and ensures video or audio monitoring equipment installed for patient safety purposes does not record and is only accessed and viewed by Veterans Affairs healthcare providers.

| 22-00069-177 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

| 22-00068-171 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager initiates an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 2   to Veterans Health Administration (VHA)

The Executive Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.

| 22-00064-172 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The System Director determines any additional reasons for noncompliance and ensures staff conduct required preventive maintenance on medical equipment.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff determines the reasons for noncompliance and ensures only authorized staff have access to medications.

No. 4   to Veterans Health Administration (VHA)

The System Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.

| 22-00231-176 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Health Care System Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews, and supervisors ensure implementation of those actions.

No. 3   to Veterans Health Administration (VHA)

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews Ongoing Professional Practice Evaluation results and documents privileging decisions in the meeting minutes.

No. 5   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures staff check supply rooms for expired supplies and discard them.

| 22-00054-158 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

No. 2   to Veterans Health Administration (VHA)

The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete environment of care inspections in patient care areas at the required frequency and document the inspection results.

No. 3   to Veterans Health Administration (VHA)

The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee tracks environment of care inspection deficiencies until they are resolved.

No. 4   to Veterans Health Administration (VHA)

The Director determines any additional reasons for noncompliance and ensures staff post signage in all areas where potentially infectious materials are present.

No. 5   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and furnishings and equipment safe and in good repair.

No. 6   to Veterans Health Administration (VHA)

The Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.

| 22-04133-163 | Summary | Report

Recommendations (12)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures peer reviewers identify at least one aspect of care when assigning a Level 2 or 3 to a peer review.

No. 2   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures the Peer Review Committee recommends improvement actions to reviewed providers.

No. 3   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations to providers and ensure they implement improvement actions for all Level 2 and 3 peer reviews.

No. 4   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.

No. 5   to Veterans Health Administration (VHA)

The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.

No. 6   to Veterans Health Administration (VHA)

The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee monitors environment of care inspection deficiencies until resolution.

No. 7   to Veterans Health Administration (VHA)

The Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on inpatient mental health unit sleeping room doors.

No. 8   to Veterans Health Administration (VHA)

The Deputy Medical Center Director ensures staff post hazard warning signs in all areas where potentially infectious materials are located.

No. 9   to Veterans Health Administration (VHA)

The Deputy Medical Center Director ensures staff keep patient care areas safe and clean.

No. 10   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures suicide prevention coordinators report suicide-related events to mental health leaders and quality management staff at least monthly

No. 11   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures designated staff complete a Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.

No. 12   to Veterans Health Administration (VHA)

The Executive Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.

| 22-00059-157 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines reasons for noncompliance and ensures clinicians complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

| 22-00051-136 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for all Level 3 peer reviews.

No. 3   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews the Protected Peer Review Committee’s summary analysis quarterly.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for professional practice evaluations.

No. 5   to Veterans Health Administration (VHA)

The Executive Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.

No. 6   to Veterans Health Administration (VHA)

The Executive Director determines the reasons for noncompliance and ensures staff post signage to indicate areas that are subject to video recording.

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