Date Issued
|
Report Number
19-06872-199
|
Topics: Patient Safety
● Medical Staff Privileging Credentialing
● Suicide Prevention
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analysis actions are implemented and properly documented in the VHA Patient Safety Information System.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that the Patient Safety Manager or designee provides an annual patient safety report to medical center leaders.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers consistently collect and review ongoing professional practice evaluation data.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Professional Standards Board meeting minutes consistently reflect the review of professional practice evaluation results when recommending continuation of privileges.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff determines reason(s) for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines reason(s) for noncompliance and ensures the departing licensed healthcare professional’s first- or second-line supervisor appropriately signs the exit review form.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director determines reason(s) for noncompliance and ensures that patient care supply areas are properly designated, and adequate temperature and humidity controls are continuously monitored and maintained.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics to the medical center.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 6/13/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff determines reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame and document the patient’s preference for telephonic follow-up, if warranted.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete safety plans in a timely manner and that all required elements—including firearm and opioid safety—are assessed for patients with High Risk for Suicide Patient Record Flags.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures clinical and nonclinical staff receive annual suicide prevention refresher training.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and appoints a multidisciplinary committee responsible for life-sustaining treatment decision reviews that includes representatives from three or more different disciplines.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that Sterile Processing Services reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services maintain required airflow parameters for areas where reusable medical equipment is reprocessed.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 8/18/2020
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that staff avoid eating, drinking, and/or storing food items in areas where decontamination, sterilization, or clean/sterile storage occurs.148
No. 26
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The Associate Director for Patient Care Services determines reason(s) for noncompliance and ensures that staff properly store endoscopes.