Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01994-18 | Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility-level senior leaders, ensures that summaries of the peer review committees’ work are reviewed quarterly by medical executive committees.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all applicable deaths within 24 hours of admission are peer reviewed.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that cardiopulmonary resuscitation committees review each resuscitative episode under the facilities’ responsibility and include required elements in reviews.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures focused professional practice evaluation criteria are defined in advance.
Closure Date:
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff document the decision to recommend continuing licensed independent practitioners’ privileges based on ongoing professional practice evaluation results.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that service chiefs’ privileging determinations are based, in part, on ongoing professional practice evaluation activities.
Closure Date:
8 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that ongoing professional practice evaluations use assessments by providers with similar training and privileges.
Closure Date:
9 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames for focused professional practice evaluations for cause with licensed independent practitioners.
Closure Date:
10 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that inventories of resources and assets that may be needed during an emergency are documented and reviewed annually.
Closure Date:
11 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that monthly and quarterly controlled substances inspection reports are reviewed at least quarterly by the facility committees responsible for quality oversight.
Closure Date:
12 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that electronic access for monitoring and performing controlled substances balance adjustments is limited to appropriate staff.
Closure Date:
13 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete monthly physical inspections of controlled substances storage areas on the day initiated.
Closure Date:
14 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities.
Closure Date:
15 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify that drugs listed on the “Destructions File Holding Report” are secured and documented and that there is a corresponding sealed evidence bag for each medication during monthly inspections.
Closure Date:
16 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify the inventory count for prescription pads on the day of monthly pharmacy inspections.
Closure Date:
17 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify written controlled substances prescriptions during monthly area inspections.
Closure Date:
18 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify pharmacy vault inventory at the required frequency.
Closure Date:
19 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete emergency drug cache inspections that include checks for lock tampering and verification of lock numbers.
Closure Date:
20 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement processes for reviewing automated drug dispensing cabinet override reports.
Closure Date:
21 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators establish and monitor related training.
Closure Date:
22 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators communicate related issues, services, and initiatives to facility leaders.
Closure Date:
23 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures mental health and primary care providers complete mandatory military sexual trauma training within the required time frame.
Closure Date:
24 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians provide and document education on newly prescribed medications and assess patient/caregiver understanding of the information provided.
Closure Date:
25 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians review and reconcile patients’ medications and maintain and communicate accurate medication information in electronic health records.
Closure Date:
26 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that women veterans health committees include required core members, meet at least quarterly, and report to leadership.
Closure Date:
27 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement quality assurance processes that include tracking of cervical cancer screening notification and follow-up care.
Closure Date:
28 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that urgent care centers operating 24 hours a day, 7 days a week have an approved waiver from the National Director of Emergency Medicine.
Closure Date:
29 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that emergency departments and urgent care centers are staffed with a minimum of two registered nurses during all hours of operation.
Closure Date:
30 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure clinical managers maintain a backup call schedule for emergency department and urgent care center providers.
Closure Date:
31 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that support services, including social work, are available to emergency departments and urgent care centers during all hours of operation.
Closure Date:
32 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities use appropriate signage to direct patients to emergency departments and urgent care centers.
Closure Date:
| ||||
| 19-07316-262 | Homemaker and Home Health Aide Program: Most Claims Paid Correctly, but Opportunities Exist to Improve Services to Veterans | Audit | ||
1 The under secretary for health assess whether current program policies and practices meet the needs of medical facilities’ local homemaker and home health aide programs and update them as necessary.
Closure Date:
2 The under secretary for health updates homemaker and home health aide program guidance to include processes that medical facilities must follow when assessing whether home health agencies are licensed or certified, meet specified conditions, or will be exempted from program requirements, to include determining a mechanism to track data on these decisions locally and nationally.
Closure Date:
3 The under secretary for health updates homemaker and home health aide program guidance to include procedures that medical facilities must follow to determine the suitability of veterans for program services when they cannot meet veterans’ program needs within the required period of time because of facility or community resource constraints.
Closure Date:
4 The under secretary for health implements procedures for medical facility directors to use data on veteran demand, including unmet demand, for homemaker and home health aide program services to manage their local program resources.
Closure Date:
5 The under secretary for health updates homemaker and home health aide program guidance to include processes that medical facilities must complete when veterans with care needs have been refused services from home health agencies because of demonstrated behavioral issues.
Closure Date:
6 The under secretary for health reviews homemaker and home health aide program claims identified in the audit sample that involved improper payments made to home health agencies and recover funds if deemed necessary.
Closure Date:
7 The under secretary for health assesses the timeliness of homemaker and home health aide program claim payments and take corrective action as necessary.
Closure Date:
8 The under secretary for health makes sure there is sufficient monitoring of processed homemaker and home health aide program claims to mitigate the risk of paying claims not consistent with the corresponding authorizations.
Closure Date:
| ||||
| 20-02826-07 | Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams | Review | ||
1 Further develop, implement, and test its strategy to reduce the exam inventory using in person, telehealth, and acceptable clinical evidence exams as safety and circumstances permit.
Closure Date:
2 Develop and implement a plan to increase the use of telehealth exams. VBA should also ensure contractors follow the Office of Disability and Medical Assessment telehealth guidance for exams that determine whether a telepresenter or specific medical equipment is required.
Closure Date:
| ||||
| 19-08411-12 | Deficiencies in Ambulatory Care Center and Emergency Department Processes at the VA Loma Linda Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director ensures that mental health clinic nursing staff are trained on documentation requirements when providing patient care and monitors compliance with training.
Closure Date:
2 The VA Loma Linda Healthcare System Director reviews the facility’s hand-off communication policy to ensure that nursing staff are aware of all circumstances in which hand-off communication must occur and takes action as necessary.
Closure Date:
3 The VA Loma Linda Healthcare System Director ensures that all nurses filling the first look nurse role obtain and document each patient’s vital signs within 10 minutes of the patient’s arrival to the Emergency Department and monitors compliance.
Closure Date:
| ||||
| 20-00129-09 | Comprehensive Healthcare Inspection of the Atlanta VA Health Care System in Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, and Value Committee consistently reviews and integrates aggregated quality, safety, and value data.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures improvement actions recommended by the Quality, Safety, and Value Committee are fully implemented and improvement changes are monitored.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date it is determined a peer review is required and, if necessary, extensions are approved in writing by the System Director.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinical managers consistently implement improvement actions recommended from peer review activities.
Closure Date:
5 The System Director determines the reasons for noncompliance and ensures that root cause analyses include all required review elements.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within 45 days.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete and document focused professional practice evaluation results in licensed independent practitioners’ profiles.
Closure Date:
9 The Chief of Staff determines the reasons for noncompliance and ensures that practitioners with similar training and privileges complete ongoing professional practice evaluations.
Closure Date:
10 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs’ determinations to continue privileges are based in part on results of ongoing professional practice evaluation activities.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff’s decisions to recommend continuation of privileges are based on focused and ongoing professional practice evaluation results and documents its decision in the meeting minutes.
Closure Date:
12 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare practitioners’ departure from the healthcare system.
Closure Date:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes psychological disease and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent prior to initiating patients on long-term opioid therapy.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator delivers at least five outreach activities each month.
Closure Date:
17 The System Director evaluates and determines any additional reasons for noncompliance and ensures all staff receive initial and annual refresher suicide prevention training.
Closure Date:
18 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Austell community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
Closure Date:
19 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings.
Closure Date:
20 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity ranges are monitored and maintained in the gastroenterology clean scope rooms.
Closure Date:
21 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
22 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all staff who reprocess reusable medical equipment complete monthly continuing education.
Closure Date:
23 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and ensures that nursing staff refrain from scanning duplicate wristbands and follow VHA bar code medication administration processes.
Closure Date:
| ||||
| 19-08542-11 | Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died | Hotline Healthcare Inspection | ||
1 The Veterans Crisis Line Director conducts a comprehensive review of the Caller’s contacts and staff documentation on the day of the Caller’s death, consults with Human Resources and General Counsel Offices, and takes action as warranted.
Closure Date:
2 The Veterans Crisis Line Director evaluates the effectiveness of current training for responders on lethal means assessment, takes action as warranted, and ensures supervisory oversight of lethal means assessments and related documentation.
Closure Date:
3 The Veterans Crisis Line Director provides written guidance on responders’ documentation of supervisory consultation and considers implementing independent supervisory documentation.
Closure Date:
4 The Veterans Crisis Line Director establishes policy and training for responders’ assessment of callers’ substance use and overdose risk, and monitors compliance.
Closure Date:
5 The Veterans Crisis Line Director expedites the decision whether to implement a standardized safety plan template and ensures completion of safety planning per Veterans Crisis Line standards.
Closure Date:
6 The Veterans Crisis Line Director evaluates the criteria for supervisory follow-up including silent monitoring criteria and internal program review outcomes and takes action, as warranted.
Closure Date:
7 The Veterans Crisis Line Director implements a system to identify caller contacts that warrant root cause analysis or other internal reviews and tracks the review process to completion and includes interviews of all relevant staff.
Closure Date:
8 The Office of Mental Health and Suicide Prevention Program Executive Director expedites efforts to develop suicide prevention strategies for weekend and holiday callers who are identified at increased risk for suicide.
Closure Date:
| ||||
| 20-00130-06 | Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center in Dublin, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are developed and documented in the Quality Executive Board
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioner profiles.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
5 The Chief of Staff determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that nonclinical staff receive the required Operation S.A.V.E. training during new employee orientation.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
Closure Date:
8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when there is only one designated provider.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned to and consistently attend Women Veterans Health Committee meetings.
Closure Date:
10 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief maintains an accurate file for all reusable medical equipment that includes the current manufacturers’ instructions for use.
Closure Date:
11 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturers’ instructions for use, are reviewed at least every three years, and are updated when there is a change.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that written records of weekly eyewash station testing are maintained.
Closure Date:
14 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and certifies that Sterile Processing Services staff complete and document liquid disinfectant solution testing to ensure the minimum effective concentration of the active ingredient is achieved.
Closure Date:
15 The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that annual airflow testing is conducted in the Gastroenterology Sterile Processing Services storage room.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and verifies that eating, drinking, and food item storage is prohibited where the processes of decontamination, sterilization, or clean and sterile storage are performed.
Closure Date:
17 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Closure Date:
| ||||
| 20-00132-04 | Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines the reasons for noncompliance and ensures that peer reviewers consistently use at least one of the nine aspects of care for evaluations.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners with similar training and privileges complete focused and ongoing professional practice evaluations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum nuclear medicine-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
Closure Date:
6 The Medical Center Director determines the reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
7 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that flooring in the inpatient behavioral health unit seclusion room is made of material that provides cushioning.
Closure Date:
8 The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual training thereafter.
Closure Date:
10 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
Closure Date:
11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders and is comprised of required core members who consistently attend meetings.
Closure Date:
12 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
Closure Date:
13 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is stored.
Closure Date:
| ||||
| 20-01326-08 | Management of the Ophthalmology Clinic and Patient Safety Reporting Concerns at the VA Central Iowa Health Care System in Des Moines | Hotline Healthcare Inspection | ||
1 The VA Central Iowa Health Care System Director ensures Ophthalmology Clinic staff are trained on how to identify, analyze, and report patient safety events and close calls.
Closure Date:
2 The VA Central Iowa Health Care System Director ensures that patient safety events and close calls are entered into the Joint Patient Safety Reporting system, and monitors for compliance.
Closure Date:
3 The VA Central Iowa Health Care System Director develops an action plan to address the culture within the Ophthalmology Clinic and monitors effectiveness.
Closure Date:
4 The VA Central Iowa Health Care System Director reviews the oversight and management of the Ophthalmology Clinic, makes recommendations for improvement, and monitors effectiveness.
Closure Date:
| ||||
| 19-08106-273 | Deficiencies in Care and Excessive Use of Restraints for a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
Closure Date:
2 The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
Closure Date:
3 The Charlie Norwood VA Medical Center Director ensures Emergency Department and Inpatient Medical Unit staff performs vital sign assessment and monitors patients who received sedating medications.
Closure Date:
4 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nurses accurately document medication administration.
Closure Date:
5 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit staff implement patient restraint management according to the Charlie Norwood VA Medical Center policy, including documentation, physician orders, and education requirements.
Closure Date:
6 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nursing staff communicate with providers regarding patients’ refusal of treatment.
Closure Date:
7 The Charlie Norwood VA Medical Center Director strengthens Inpatient Medical Unit nicotine replacement therapy processes and monitors compliance.
Closure Date:
8 The Charlie Norwood VA Medical Center Director strengthens processes to include the patient, family members, or surrogate in informed consent procedures and treatment decisions, as appropriate, and monitors compliance.
Closure Date:
9 The Charlie Norwood VA Medical Center Director evaluates the inpatient mental health consult process, and addresses timeliness and completion of decision-making capacity consult requests, and monitors compliance.
Closure Date:
10 The Charlie Norwood VA Medical Center Director consults with the Office of General Counsel regarding policies related to the management of patients presenting under a Form 1013 and advises policy and practices consistent with Georgia State mental health laws and takes action, as appropriate.
Closure Date:
11 The Charlie Norwood VA Medical Center Director ensures staff adhere to inter-facility transfer policies and procedures, including accurate communication of patients’ restraint management status, and monitors compliance.
Closure Date:
12 The Charlie Norwood VA Medical Center Director ensures that a consultation liaison psychiatrist is included on code gray teams at both divisions.
Closure Date:
13 The Charlie Norwood VA Medical Center Director evaluates inpatient mental health consult staffing and establishes a plan to ensure adequate staffing to complete consult requests as required without outpatient mental health appointment cancellations and monitors compliance.
Closure Date:
14 The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
Closure Date:
15 The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
Closure Date:
16 The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee reviews patient record flags and provides input into patients’ management to mitigate violence, as required by Veterans Health Administration, and monitors compliance.
Closure Date:
17 The Charlie Norwood VA Medical Center Director makes certain that staff receive education in code gray policy and procedures, including completion of the code gray evaluation form, and monitors compliance.
Closure Date:
18 The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee provides oversight of the code gray team activities, as required by Charlie Norwood VA Medical Center policy, and monitors compliance.
Closure Date:
| ||||
14957