Date Issued
|
Report Number
18-04682-256
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director ensures the patient safety manager includes all required content in each root cause analysis and monitors patient safety manager’s compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The director ensures the Intensive Care Unit/Cardiopulmonary Resuscitation Committee conducts a complete analysis of resuscitative episodes that includes all required elements and monitors committee’s compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff ensures that service chiefs define and communicate expectations for focused professional practice evaluations in advance and maintain appropriate documentation of the process and monitors service chiefs’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff makes certain that the service chiefs document the focus professional practice evaluation results in the practitioner profiles and monitors service chiefs’ compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The chief of staff ensures that service chiefs include the minimum-required specialty-specific criteria for professional practice evaluations of gastroenterology and nuclear medicine practitioners and monitors service chiefs’ compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff makes certain that the Medical Executive Committee documents its decision to recommend privileges based on professional practice evaluation results when recommending approval of privileges to the director and monitors committee’s compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director reports privileging actions taken by the facility to the National Practitioner Data Bank and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The associate director ensures that the VA Police regularly test panic alarms and document results and monitors staff compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director makes certain that controlled substances program staff reconcile one day’s stocking/refilling from the pharmacy to each dispensing area and one day’s return of stock to pharmacy from every automated dispensing unit during monthly inspections and monitors coordinator’s compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director confirms that the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and assessed for documentation of two signatures for any waste of partial doses and monitors coordinator’s compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director makes certain that the controlled substances coordinator validates that monthly inventories of controlled substances are conducted as required in the pharmacy and monitors coordinator’s compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 10/14/2020
The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff confirms that the military sexual trauma coordinator communicates the status of military sexual trauma-related issues, services, and initiatives to facility leadership and monitors coordinator’s compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 3/25/2021
The chief of staff confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director ensures the appointment of a women’s health medical director or clinical champion.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The facility director ensures the facility has a Women Veterans Health Committee that has an active charter, meets at least quarterly, and reports to leadership with signed minutes and monitors committee’s compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 10/14/2020
The facility director makes certain that facility staff implement a process to track and monitor cervical cancer screenings, results reporting, and follow-up care and monitors assigned staff compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 10/14/2020
The chief of staff ensures patient notification of abnormal cervical results are completed within the required time frame and monitors compliance.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff makes certain that a backup call schedule is maintained for urgent care center providers and monitors compliance.