Open Recommendations

The Executive Director ensures staff keep patient care areas clean and safe.

Facility leaders ensure staff conduct a risk assessment for electrical cord management to identify and implement any needed improvements.

The Executive Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present and store clean and dirty items separately.

The Executive Director ensures prompt disposal of biohazardous waste.

Facility leaders ensure staff conduct a risk assessment on liquid nitrogen use and storage, to include devices in exam rooms, and implement changes accordingly.

The Executive Director ensures the Comprehensive Environment of Care Committee identifies at least one facility-specific environment of care trend and establishes a performance improvement plan, including outcome measures, to address it.

Facility leaders ensure staff develop service-level workflows for the communication of test results for each service.

Facility leaders review the test result communication policy to ensure it complies with the VHA requirement for communicating critical results outside of normal business hours.

Facility leaders develop a formal process for staff to track performance metrics for test result communication, implement improvement actions, and report compliance to an appropriate oversight committee.

Facility leaders manage panel sizes to ensure patients have timely access to high-quality care.

The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patients care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.

The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessments administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses adherence; and conducts audits to ensure improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.

The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.

The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administrations nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.

The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.

The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.

The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.

The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint site disposition and related RCSNet documentation.

Facility leaders ensure staff follow facility policies and maintain a clean environment.

Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.

Executive leaders monitor the effectiveness of the patient notification process.

Periodically perform a physical inventory of all mobile devices, including those pending disposal, to ensure all assets are accounted for and accurately reflected in the asset tracking system.

Assign assessors to perform tests of effectiveness on all DFC’s System Security Plan with a sufficient degree of independence in accordance with National Institute of Standards and Technology Special Publication 800-53A, Assessing Security and Privacy Controls in Information Systems and Organizations, Revision 5.1.1.

Document the independence of the assessment team in the risk assessment, including organizational relationships, contract structures, if applicable, and oversight arrangements.