Date Issued
|
Report Number
17-01755-61
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/27/2018
The Facility Director ensures the Patient Safety Manager submits an annual patient safety report to facility leaders at the completion of each fiscal year and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Facility Director and Chief of Staff ensure that Executive Leadership Board and Peer Review Committee meeting minutes accurately reflect action status and that items are tracked to closure and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures the anticoagulation management program policy is revised to include the transition of patients between the inpatient and outpatient care settings and an anticoagulation quality assurance program.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The Chief of Staff and Associate Director for Patient Care Services ensure that anticoagulation management program quality assurance data from all sites of care are collected, analyzed, and reported biannually to the Pharmacy and Therapeutics Committee and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Associate Director for Patient Care Services ensures that annual anticoagulation management program competency assessments include all required content and that employees assigned to this program complete competency assessments as required and monitors compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Facility Director ensures the facility’s revised inter-facility transfer policy includes all required elements.
No. 10
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently document patient or surrogate informed consent, medical and behavioral stability, and identification of transferring and receiving provider or designee and monitors providers’ compliance.
No. 11
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Associate Director for Operations ensures designated team members conduct environment of care rounds in clinical and nonclinical areas as required and monitors compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Associate Director for Operations ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures that providers include an airway assessment and history of previous adverse experience with sedation or anesthesia in the history and physical exam and/or pre-sedation assessment and monitors the providers’ compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/27/2018
The Chief of Staff ensures that providers provide and document informed consent prior to moderate sedation administration and monitors providers’ compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The Chief of Staff ensures clinical teams conduct and document timeouts prior to moderate sedation procedures, the privileged provider participates in the timeout, and staff use a checklist that includes all required elements and monitors compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 7/3/2018
The Chief of Staff ensures Community Nursing Home Oversight Committee meetings include participation by all required disciplines and monitors compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 8/27/2018
The Associate Director for Patient Care Services ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.