| Text of Recommendation | 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. |
|---|---|
| Recommendation Number | 01 |
| Recommendation Status | Closed |
| Significant Recommendation | No |
| Recommendation Questioned Costs | $0 |
| Recommendation Funds for Better Use | $0 |
| Submitting OIG | |
|---|---|
| Report Title | Comprehensive Healthcare Inspection of the Butler VA Health Care System in Pennsylvania |
| Report Submitting OIG-Specific Report Number | 22-00068-171 |
| Report Date Issued | Thursday, August 10, 2023 |
| Report Agency Reviewed / Investigated | |
| Report Questioned Costs | $0 |
| Report Funds for Better Use | $0 |