Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-00130-241 | Comprehensive Healthcare Inspection of the Birmingham VA Medical Center in Alabama | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director determines the reasons for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and makes certain that the service chief includes the minimum pathology-specific criteria for focused professional practice evaluations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific criteria for ongoing professional practice evaluations.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare practitioner’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of departure from the medical center.
Closure Date:
6 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that medical center managers keep furnishings and equipment safe and in good repair.
Closure Date:
7 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that Environmental Management Services staff separate clean and dirty equipment, devices, and supplies.
Closure Date:
8 The Associate Director evaluates and determines any additional reasons fornoncompliance and ensures that medical center managers maintain safe, functional,and clean patient care areas.
Closure Date:
9 The Associate Director evaluates and determines any additional reasons fornoncompliance and ensures that staff secure protected health information withinlaboratory transport containers.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of untreated substance abuse, unstable psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain providers document justification for prescribing opioids and benzodiazepines concurrently.
Closure Date:
12 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:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans are completed within seven days before or after the High Risk for Suicide Patient Record Flag designation.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans include all required elements for patients with High Risk for Suicide Patient Record Flags.
Closure Date:
16 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that clinical and nonclinical staff complete annual suicide prevention refresher training.
Closure Date:
17 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:
18 The Associate Director for Patient/Nursing 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:
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| 19-09493-249 | Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee | Hotline Healthcare Inspection | ||
1 The Memphis VA Medical Center Director evaluates the current process for patients discharged from the Emergency Department who need to be seen the same day in the Outpatient Mental Health Clinic for medication management, establishes a clear referral process to the Outpatient Mental Health Clinic, and verifies that patients receive the care needed.
Closure Date:
2 The Memphis VA Medical Center Director reviews the Emergency Department Mental Health Handbook and defines a clear process for medication management in the Emergency Department, and ensures that patients receive same day psychiatric medication management when indicated.
Closure Date:
3 The Memphis VA Medical Center Director evaluates the current process for Emergency Department physicians to refer patients to the Emergency Department mental health provider for a mental health assessment and verifies that patients who require mental health provider assessment receive the care needed.
Closure Date:
4 The Memphis VA Medical Center Director reviews the current medication reconciliation processes in the Emergency Department and Primary Care Clinics and verifies that providers complete and document medication reconciliation in accordance with policy and makes changes as necessary.
Closure Date:
5 The Memphis VA Medical Center Director assesses the Outpatient Mental Health Clinic check-in process and verifies mental health patients are registered, triaged, and receive mental health services as needed.
Closure Date:
6 The Memphis VA Medical Center ensures that patients are offered the option of community care consult, as appropriate.
Closure Date:
7 The Memphis VA Medical Center Director evaluates the outpatient consult process and verifies that providers manage discontinued consults appropriately.
Closure Date:
8 The Memphis VA Medical Center Director evaluates the process for community care clinical oversight, clarifies who has responsibility for coordinating care for patients receiving mental health in the community, and verifies that patients receive authorized community mental health care.
Closure Date:
9 The Memphis VA Medical Center Director evaluates the process for timely retrieval of medical records from community care providers, verifies the medical records are uploaded into patients’ electronic health records, and takes action as necessary.
Closure Date:
10 The Memphis VA Medical Center Director evaluates the clinical review process for community care authorizations, ensures staff are trained on the process, verifies that authorizations have clinical delegate review, and are processed timely.
Closure Date:
11 The Memphis VA Medical Center Director reviews the complaint reporting, responding and tracking processes and ensures that complaints are addressed, resolved, and documented in accordance with current facility policy.
Closure Date:
12 The Memphis VA Medical Center Director ensures leaders and supervisors are trained on initiating and conducting a fact finding.
Closure Date:
13 The Memphis VA Medical Center Director considers conducting further review to address the differing accounts of the Emergency Department physician and Emergency Department mental health provider regarding the patient referral to ascertain whether the Emergency Department failed to follow facility policy, and takes action if needed.
Closure Date:
14 The Memphis VA Medical Center Director ensures that responsible staff receive training on completing behavioral autopsy reports as required by the Veterans Health Administration Behavioral Health Autopsy Program and verifies that behavioral autopsies are completed in accordance with policy.
Closure Date:
15 The Memphis VA Medical Center Director reviews the issue brief reporting requirements with supervisors and ensures timely issue brief reporting for patients who die by suicide.
Closure Date:
16 The Memphis VA Medical Center Director ensures that staff who conduct root cause analyses are trained on the guidelines for interviewing individuals vital to the root cause analysis charter and identified processes, and verifies the root cause analysis interview guidelines are followed.
Closure Date:
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| 20-00130-194 | Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director determines the reason(s) for noncompliance and ensures egresses are free of blockages.
Closure Date:
2 The Associate Director determines the reason(s) for noncompliance and ensures damaged wheelchairs are repaired or removed from service.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that the Suicide Prevention Coordinator ensures completion and documentation of at least five outreach activities each month.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers document all required elements of goals of care conversations.
Closure Date:
6 The Medical Center Director evaluates and determines reason(s) for noncompliance and certifies that the multidisciplinary committee responsible for life-sustaining treatment decision reviews include three or more different disciplines and at least one member from the medical center’s Ethics Consultation Service.
Closure Date:
7 The Medical Center Director determines the reason(s) for noncompliance and ensures that the multidisciplinary committee reviews life-sustaining treatment plans for patients who lack decision-making capability and do not have a surrogate.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
Closure Date:
9 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations maintains an accurate file of all reusable devices that includes current manufacturers’ instructions for use.
Closure Date:
10 The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and makes certain that the CensiTrac® instrument tracking system is installed and operational.
Closure Date:
11 The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
12 The Associate Director evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services areas are cleaned as scheduled.
Closure Date:
13 The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
Closure Date:
14 The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services staff receive competency assessments for reprocessing reusable medical equipment.
Closure Date:
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| 18-03800-232 | Financial Management Practices Can Be Improved to Promote the Efficient Use of Financial Resources | Audit | ||
1 The OIG recommended the executive in charge, Office of the Under Secretary for Health, establish financial controls, such as key performance indicators, that align with medical center operations and can be used to assess the efficient use of operating funds.
Closure Date:
2 Specify the accountable Veterans Health Administration office responsible for establishing financial controls to ensure Veterans Health Administration’s financial management activities promote the efficient use of funds at Veterans Integrated Service Networks.
Closure Date:
3 The OIG recommended the executive in charge, Office of the Under Secretary for Health, require the Veterans Health Administration to establish and publish organizational charts that identify the appropriate financial management reporting lines of authority and to develop familiarization training on the reporting lines of authority at the VISN and medical center levels, as appropriate.
Closure Date:
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| 20-02794-218 | Appointment Management During the COVID-19 Pandemic | Review | ||
1 The OIG recommended the under secretary for health develop and clearly communicate a well defined strategic plan to all medical facilities for rescheduling patients and provide oversight particularly to those facilities with the highest rates of canceled appointments with no evidence of follow up or tracking.
Closure Date:
2 The OIG recommended the under secretary for health develop a mechanism to monitor facilities’ progress with following up on all cancellations to ensure facilities are not solely relying on COVID annotations or cancellation source classifications when rescheduling.
Closure Date:
3 The OIG recommended the under secretary for health ensure that facilities take appropriate follow up action on canceled or discontinued consults.
Closure Date:
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| 20-00064-238 | Comprehensive Healthcare Inspection of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures improvement action items recommended by the Quality Council are fully implemented and monitored.
Closure Date:
2 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain the Patient Flow Committee meeting minutes reflect documentation, implementation, and evaluation of action items.
Closure Date:
3 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
4 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures service chiefs document focused professional practice evaluation results in provider profiles.
Closure Date:
5 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of initially granted privileges.
Closure Date:
6 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation criteria.
Closure Date:
7 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete licensed independent practitioners’ ongoing professional practice evaluations.
Closure Date:
8 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the center.
Closure Date:
9 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers repair or remove damaged wheelchairs from service.
Closure Date:
10 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers maintain a safe and clean environment.
Closure Date:
11 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures adequate privacy is provided in patient examination rooms at the Evanston VA Clinic.
Closure Date:
12 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures the information technology room at the Evanston VA Clinic is secure and restricted to authorized personnel.
Closure Date:
13 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions.
Closure Date:
14 The Healthcare Center Director determines the reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
Closure Date:
15 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures that clinicians at community-based outpatient clinics provide integrated mental health services for women veterans.
Closure Date:
16 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when clinics have only one provider.
Closure Date:
17 The Healthcare Center Director 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:
18 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures the Women’s Health Medical Director collects, tracks, and reports quality assurance data.
Closure Date:
19 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services aligns standard operating procedures with manufacturers’ guidelines and instructions for use.
Closure Date:
20 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services enters all equipment into the CensiTrac® Instrument Tracking System.
Closure Date:
21 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
22 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff conduct annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
Closure Date:
23 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Engineering Service or designee conduct and maintain the record of weekly eyewash station function testing.
Closure Date:
24 The Associate Director for Facilities Support determines the reasons for noncompliance and makes certain the Environmental Management Supervisor develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
Closure Date:
25 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are properly stored by Sterile Processing Services and clinical staff.
Closure Date:
26 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
Closure Date:
27 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 20-02240-248 | Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon | Hotline Healthcare Inspection | ||
1 The Portland VA Health Care System Director ensures that a consistent notification process is implemented and monitored to ensure the sending department notifies the receiving department of a patient’s potential infectious disease status prior to transfer and verifies appropriate infection control precautions are implemented prior to transfer.
Closure Date:
2 The Portland VA Health Care System Director ensures that the standard process for contact tracing for staff exposure to high-consequence infections such as COVID-19 includes a process for identification of potentially exposed staff who cannot be identified through electronic health record documentation.
Closure Date:
3 The Portland VA Health Care System Director ensures that standard processes for assessment of staff exposure to high-consequence infections such as COVID-19, including a process for validation of supervisors’ initial risk categorizations, are implemented and monitored to support reliable and accurate exposure risk categorization.
Closure Date:
4 The Portland VA Health Care System Director ensures that standard processes are implemented and monitored for tracking staff exposure, providing guidance on self-monitoring, self-quarantine, and returning to work, and documenting Employee Health Service contacts with exposed employees.
Closure Date:
5 The Portland VA Health Care System Director ensures facility policies are reviewed and updated to include a detailed staff exposure management process to leverage lessons learned from the current pandemic response and to enhance preparedness for future events.
Closure Date:
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| 20-00075-225 | Comprehensive Healthcare Inspection of the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are documented in Quality Management Oversight Committee minutes when problems or opportunities for improvement are identified.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria in practitioner profiles for focused professional practice evaluations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate, complete, and document the results of focused professional practice evaluations in practitioner profiles.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
Closure Date:
7 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
8 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs consistently collect and review ongoing professional practice evaluation data for the determination to recommend continuation of privileges.
Closure Date:
9 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that licensed independent practitioners’ ongoing professional practice evaluations are completed by providers with similar training and privileges.
Closure Date:
10 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Medical Executive Committee meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
Closure Date:
11 The Medical Center 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 professionals departing the medical center.
Closure Date:
12 The Assistant Director evaluates and determines any additional reasons for noncompliance and makes sure that biohazardous rooms are not used to store clean items.
Closure Date:
13 The Assistant Director determines the reasons for noncompliance and ensures that clean/sterile storeroom solid-bottom shelves are clean.
Closure Date:
14 The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center and outpatient clinic buildings.
Closure Date:
15 The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures that patient care equipment is clean and ready for use.
Closure Date:
16 The Medical Center Director ensures that Office of Information Technology leaders determine the reasons for noncompliance and ensures that access is controlled to information technology rooms.
Closure Date:
17 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment to include a history of substance abuse and psychological disease on all patients prior to initiating long-term opioid therapy.
Closure Date:
18 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
Closure Date:
19 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent consistently for patients who are initiating long-term opioid therapy.
Closure Date:
20 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within three months and assess adherence to the pain management plan of care and effectiveness of interventions.
Closure Date:
21 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the prescribed time frame and include documentation of the patient’s preference for a telephone call, if applicable.
Closure Date:
22 The Chief of Staff determines the reasons for noncompliance and ensures that processes and procedures are in place to ensure gynecological care is available 24 hours a day, 7 days per week.
Closure Date:
23 The Medical Center Director determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings and report to executive leaders.
Closure Date:
24 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that required quality assurance data related to women veterans’ health care services are collected and tracked for improvement opportunities.
Closure Date:
25 The Chief of Staff determines the reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
Closure Date:
26 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs and documents an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
27 The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that the written cleaning schedule for Sterile Processing Services is enforced.
Closure Date:
28 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected scopes are stored properly.
Closure Date:
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| 20-00069-222 | Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital in Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are monitored and documented in the Quality Board minutes when problems or opportunities are identified.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths within 24 hours of admission are peer reviewed.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analyses is reviewed quarterly by the Medical Executive Board.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate and complete focused professional practice evaluations on all newly hired licensed independent practitioners.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum pathology and radiation oncology specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs collect, review, and use ongoing professional practice evaluation data in determinations to continue current privileges.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decisions to recommend initial and continuation of privileges are based on focused and ongoing professional practice evaluation results.
Closure Date:
9 The Medical Center 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 professionals departing the medical center.
Closure Date:
10 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees remove expired commercial sterile supplies from service.
Closure Date:
11 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures clinical areas are in good repair and that a safe and clean environment is maintained throughout the medical center.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers complete pain screening for all patients prior to initial dispensing of long-term opioid therapy.
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 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 for patients who are initiating long-term opioid therapy.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that follow-up with patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and the effectiveness of the intervention.
Closure Date:
17 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
Closure Date:
18 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that at least 10 percent of reprocessed endoscopes are tested for bioburden.
Closure Date:
19 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that traffic flow in the gastroenterology clean storage area is restricted.
Closure Date:
20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
Closure Date:
21 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff complete Level 1 training within 90 days of hire
Closure Date:
22 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services Chief complete competency assessments for staff reprocessing reusable medical equipment.
Closure Date:
23 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 19-09669-236 | Inadequate Inpatient Psychiatry Staffing and Noncompliance with Inpatient Mental Health Levels of Care at the VA Central Western Massachusetts Healthcare System in Leeds | Hotline Healthcare Inspection | ||
1 The VA Central Western Massachusetts Healthcare System Director ensures adequate psychiatry staffing to afford providers adequate time for direct patient care on the acute and subacute inpatient mental health units.
Closure Date:
2 The VA Central Western Massachusetts Healthcare System Director provides ongoing monitoring and evaluation of acute and subacute unit medical provider staffing.
Closure Date:
3 The VA Central Western Massachusetts Healthcare System Director ensures that the utilization management plan accurately reflects and is compliant with all Veterans Health Administration requirements.
Closure Date:
4 The VA Central Western Massachusetts Healthcare System Director makes certain medical officers on duty complete inpatient mental health admission medical clearance assessments in accordance with Central Western Massachusetts Healthcare System and Veterans Health Administration policies.
Closure Date:
5 The VA Central Western Massachusetts Healthcare System Director makes certain that recovery-oriented programming occurs as scheduled and consists of at least four hours per day.
Closure Date:
6 The VA New England Health Care System Director develops business plans for restructuring of clinical programs to include transitioning sustained treatment and rehabilitation beds, subacute unit beds, and specialized inpatient posttraumatic stress disorder beds as required by the Veterans Health Administration.
Closure Date:
7 The VA Central Western Massachusetts Healthcare System Director consults with Veterans Integrated Service Network 1 leaders to determine and implement a process to monitor clinical appropriateness for patients in all inpatient mental health beds, including sustained treatment and rehabilitation beds until restructuring of clinical programs is complete.
Closure Date:
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