Date Issued
|
Report Number
14-02890-247
All Reports
Date Issued
|
Report Number
16-00106-211
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the availability of personal protective equipment masks in all patient care areas and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
We recommended that employees secure medication carts when not in use, remove expired medications from patient care areas, and date multi-dose vials when opened and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
We recommended that a medical physicist complete and document inspections of computed tomography scanners following repair or modifications affecting dose or image quality and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/7/2017
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that treatment teams follow up with patients at least four times during the first 30 days after discharge and that facility managers monitor compliance.
Date Issued
|
Report Number
15-01283-220
Date Issued
|
Report Number
14-02890-175
Date Issued
|
Report Number
14-03145-176
Date Issued
|
Report Number
14-02890-217
Date Issued
|
Report Number
14-02890-192
Date Issued
|
Report Number
14-02890-202
Date Issued
|
Report Number
14-02890-229
Date Issued
|
Report Number
16-00007-206
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended that managers monitor hand hygiene compliance at the 46th Street VA Mental Health and Eye Clinics.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended that the Facility Director ensures the development and implementation of a policy for the management of clinical and mental health emergencies at the 46th Street South VA Eye Clinic.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended that the Facility Director ensures documentation of a Hazard Vulnerability Assessment to identify potential emergencies at the Forty Sixth Street South VA Mental Health Clinic.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that clinic managers ensure that sterile commercial supplies at the 46th Street South VA Eye Clinic are not expired.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended that clinic managers review the Forty Sixth Street South VA Mental Health Clinic’s hazardous materials inventory twice within a 12-month period.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/23/2016
We recommended that clinic managers provide feminine hygiene disposal bins in women’s public restrooms at the 46th Street South VA Mental Health Clinic.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/1/2016
We recommended that clinic managers at the 46th Street South VA Mental Health and Eye Clinics ensure the information technology server closet is maintained according to information technology safety and security standards.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/13/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Date Issued
|
Report Number
15-04709-208
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/21/2016
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/23/2016
We recommended that facility managers ensure damaged equipment in patient care areas is repaired or removed from service and stained/missing ceiling tiles are replaced.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/4/2016
We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/4/2016
We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/21/2016
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/4/2016
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Date Issued
|
Report Number
14-02890-225
Date Issued
|
Report Number
14-02890-171
Date Issued
|
Report Number
14-02890-216
Date Issued
|
Report Number
14-02890-228
Date Issued
|
Report Number
14-02890-233
Date Issued
|
Report Number
14-02890-219
Date Issued
|
Report Number
16-01031-142
Date Issued
|
Report Number
16-01027-141
Date Issued
|
Report Number
14-02890-214