Combined Assessment Program Review of the St. Louis VA Medical Center St. Louis, Missouri

The purpose was to evaluate selected activities, focusing on patient care administration and quality management, and to provide crime awareness training. We conducted the review the week of June 13, 2011. Review Results: The review covered eight activities. We made no recommendations in the following activity: ? Medication Management Recommendations: We made recommendations in the following seven activities: Quality Management: Analyze aggregate data, document discussions, and make recommendations based on the analysis. Require written requests for peer review extensions to be submitted to the facility Director and approved in writing prior to the 120-day deadline. Physician Credentialing and Privileging: Ensure physicians complete the required training regarding medications used for moderate sedation. Coordination of Care: Update facility advance directive policy to define staff responsibilities, and ensure all components of notification and screening are provided and documented in the medical record. Enteral Nutrition Safety: Revise facility enteral nutrition and infection control policies, and monitor compliance with the updated policies. Ensure enteral nutrition documentation includes all required elements. Provide written instructions to patients discharged with enteral nutrition, and document receipt. Registered Nurse Competencies: Consistently follow the established process for competency assessment and validation, identify competencies that are consistent with individual nursing assignments, ensure competency validation documentation is complete, and specify the methods used to assess and validate competency. Management of Workplace Violence: Write and implement a comprehensive workplace violence policy that includes a training plan. Environment of Care: Ensure designated staff complete annual N95 respirator fit testing, and monitor compliance.