Date Issued
|
Report Number
15-00618-02
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended that the Facility Director and other key members required by local policy attend Quality Committee meetings or have a delegate represent them.
No. 2
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 3
to Veterans Health Administration (VHA)
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
to Veterans Health Administration (VHA)
We recommended that the facility analyze electronic health record quality data at least quarterly.
No. 5
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 6
to Veterans Health Administration (VHA)
We recommended that the Chief of Staff complete an audit of all licensed independent practitioners’ privileges to ensure they are current and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the health care occupancy building has at least one fire drill during administrative hours per quarter and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that the facility revise the tuberculosis prevention plan policy to reflect current status of negative air exchange rooms in the primary care clinic and ensure employees are aware of procedures to care for infectious patients in lieu of negative air exchange rooms.
No. 10
to Veterans Health Administration (VHA)
We recommended that facility managers ensure correction of all deficiencies identified during annual physical security surveys.
No. 11
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently complete a physical count of all primary care clinics during the 1st month of each quarter and a physical count of 10 line items for all primary care clinics during the 2nd and 3rd months of each quarter and that the Controlled Substances Coordinator monitors compliance.
No. 12
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently complete pharmacy inspections on the same day initiated and that the Controlled Substances Coordinator monitors compliance.
No. 13
to Veterans Health Administration (VHA)
We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
We recommended that clinicians communicate incomplete or “probably benign” results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
We recommended that clinicians ensure all patients assessed to be at high risk for suicide have documented safety plans that specifically address suicidality and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
We recommended that clinicians ensure that patients and/or their families receive a copy of the safety plan and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team and a centralized disruptive behavior reporting and tracking system.
No. 20
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that monthly self-inspection documentation includes safety, security, and privacy.
No. 21
to Veterans Health Administration (VHA)
We recommended that the facility Risk Manager continue the recently implemented peer review corrective action tracking process and ensure actions are completed and reported to the Peer Review Committee.
No. 22
to Veterans Health Administration (VHA)
We recommended that facility managers consistently initiate Focused Professional Practice Evaluations for newly hired licensed independent practitioners at the time or before they begin providing patient care.