Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-06378-73 | Deficiencies in the Women Veterans Health Program and Other Quality Management Concerns at the North Texas VA Healthcare System | Hotline Healthcare Inspection | ||
1 The VA North Texas Health Care System Director takes steps to ensure sufficient staffing to provide gender-specific care by designated women’s health primary care providers.
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2 The VA North Texas Health Care System Director ensures steps are taken to reduce panel sizes of designated women’s health primary care providers as required by Veterans Health Administration policy.
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3 The VA North Texas Health Care System Director reviews the Veterans Health Administration policy recommended extended appointment times for comprehensive women veterans healthcare examinations and takes action as appropriate to achieve compliance.
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4 The VA North Texas Health Care System Director takes steps to ensure that appropriate resources, such as equipment, supplies, and space, are adequate to support comprehensive women veterans healthcare.
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5 The VA North Texas Health Care System Director takes steps to ensure that the Women Veterans Program Manager participates in the environment of care rounds and monitors for compliance with Veterans Health Administration policy.
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6 The VA North Texas Health Care System Director evaluates clinic areas where gender specific primary care is currently provided and when planning renovations to existing areas to ensure adequate restroom access for women veterans and takes action as appropriate.
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7 The VA North Texas Health Care System Director continues to evaluate and support staffing changes in the gynecology specialty clinic to enhance services.
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8 The VA North Texas Health Care System Director ensures implementation of an effective tracking mechanism to ensure VA providers receive results for women veterans referred to care in the community and monitors for compliance with Veterans Health Administration policy.
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9 The VA North Texas Health Care System Director verifies review of the electronic health records of women veterans referred to Care in the Community whose medical records have not been obtained and takes action if indicated.
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10 The VA North Texas Health Care System Director takes steps to ensure performance and evaluation processes provide the intended assessment of compliance with Veterans Health Administration requirements and monitors for compliance.
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11 The VA North Texas Health Care System Director verifies that institutional disclosures are conducted for events that meet disclosure criteria and monitors for compliance with Veterans Health Administration policy.
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12 The VA North Texas Health Care System Director takes steps to ensure the required number of combined totals of root cause analyses and aggregated reviews are completed, and monitors for compliance with Veterans Health Administration policy.
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13 The VA North Texas Health Care System Director ensures completion of root cause analyses within the required timeframes and monitors for compliance with Veterans Health Administration policy.
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14 The VA North Texas Health Care System Director verifies that staff complete training on policy related to high-risk patient goals of care conversations for life-sustaining treatment plans and monitors for completion of training.
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15 The VA North Texas Health Care System Director ensures staff conduct high-risk patient goals of care conversations for life-sustaining treatment plans as required and monitors for compliance with Veterans Health Administration policy.
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16 The VA North Texas Health Care System Director takes steps to ensure provider documentation of high-risk patient goals of care and life-sustaining treatment plan in the required electronic health record template and monitors for compliance with Veterans Health Administration policy.
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17 The VA North Texas Health Care System Director verifies capture and reporting of all codes to the resuscitation subcommittee and monitors for compliance with Veterans Health Administration policy.
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18 The VA North Texas Health Care System Director ensures that the Critical Care Committee minutes reflect corrective action plans and follow-through to remediate concerns identified by the resuscitation subcommittee and monitors for compliance.
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| 19-07070-75 | A Delay in Patient Notification of Test Results and Other Communication Issues at the Bath VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Bath VA Medical Center Director ensures that surrogate providers comply with the facility’s notification policy when providing coverage.
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2 The Bath VA Medical Center Director ensures that the Bath VA Medical Center Patient Transfer Policy clearly defines a process for outpatient transfers to a higher level of care utilizing facility paramedics.
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| 18-00711-42 | Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Cincinnati Education and Research for Veterans Foundation | Audit | ||
1 The Cincinnati Veterans Affairs Medical Center director ensures the Cincinnati Education and Research for Veterans Foundation’s board of directors establishes policies that require responsible officials to verify adequate supporting documentation before approving expenditures.
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2 The Cincinnati Veterans Affairs Medical Center director ensures the Cincinnati Education and Research for Veterans Foundation’s board of directors, or responsible officials, approve reimbursements to the executive director.
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3 The Cincinnati VA Medical Center director establishes procedures to ensure Research and Development Budget Office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with Intergovernmental Personnel Act agreements prior to approving invoices for payment.
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4 The Cincinnati VA Medical Center director establishes procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
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| 18-05121-36 | Improvements Are Needed in the Community Care Consult Process at VISN 8 Facilities | Audit | ||
1 Develop and implement a mechanism for VA facilities and their respective VA community care departments to routinely identify and exchange wait time data to help make decisions that reduce patient wait times.
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2 Routinely monitor the timeliness of each distinct stage of the community care consult process so Veterans Integrated Service Network 8 facilities can identify specific delays.
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3 Ensure facilities routinely monitor the Office of Community Care staffing tool and take appropriate actions to confirm actual staffing levels are sufficient to meet workloads in a timely manner.
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4 Ensure community care administrative staff are effectively cross-trained to carry out applicable administrative consult processing duties to streamline scheduling and authorizations, and implement a control to monitor whether facilities are processing community care consults in accordance with Office of Community Care guidance and recommendations.
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5 Develop and implement specific facility plans to address the backlog of open consults and the growing number of new consults.
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| 19-00046-60 | Comprehensive Healthcare Inspection of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that required representatives participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
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2 The chief of staff ensures that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
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3 The chief of staff confirms clinical staff responding to resuscitation events have basic or advanced cardiac life support certification and monitors clinical staff compliance.
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4 The chief of staff ensures service chiefs include defined time frames in focused professional practice evaluations and monitors service chiefs’ compliance.
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5 The chief of staff confirms that service chiefs ensure that focused professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
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6 The chief of staff makes certain service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
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7 The chief of staff confirms that service chiefs ensure that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
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8 The chief of staff makes certain that service chiefs clearly define and share in advance with providers the time frame, expectations, and outcomes for focused professional practice evaluations for cause that do not limit providers’ ability to practice independently for more than 30 days and monitors service chiefs’ compliance.
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9 The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
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10 The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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11 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
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12 The chief of staff ensures clinicians review and reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
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13 The facility director ensures that the facility has a full-time women veterans program manager.
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14 The chief of staff confirms that the Women Veterans Health Committee includes required core members and reports to a clinical executive level committee and monitors the committee’s compliance.
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15 The chief of staff ensures that program managers implement a process to track and monitor cervical cancer screenings and follow-up care and monitors program managers’ compliance.
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16 The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
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17 The chief of staff ensures the chief of Social Work maintains a backup call schedule for emergency department social workers.
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| 19-00034-62 | Comprehensive Healthcare Inspection of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors for compliance.
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2 The facility director ensures that facility leaders review a Patient Safety Annual Report at the end of the fiscal year and monitors the patient safety manager’s compliance.
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3 The chief of staff ensures that the Code Blue/Rapid Response Team Committee reviews each resuscitative episode and monitors committee compliance.
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4 The facility director ensures that the controlled substance coordinator provides the monthly summary of findings and quarterly trends report to the director and monitors the controlled substance coordinator’s compliance.
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5 The facility director makes certain that the Quality Executive Board reviews the controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
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6 The facility director makes certain that the controlled substances coordinator performs and documents competency assessments of the controlled substance inspectors annually and monitors controlled substances coordinator’s compliance.
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7 The facility director makes certain the controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors the inspectors’ compliance.
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8 The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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9 The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
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10 The facility director confirms that the Women Veterans’ Advisory Committee is comprised of the required core members and monitors committee’s compliance.
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11 The facility director ensures that urgent care center patients are assigned the appropriate stop codes to capture correct patient workload, productivity, and level of service and monitors compliance.
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12 The chief of staff ensures that a written provider staffing contingency plan and backup call schedule are maintained for urgent care center providers and monitors compliance.
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13 The facility director confirms that the urgent care center implements the Emergency Department Integration Software tracking program and transmits data to the Emergency Medicine Management Tool and monitors compliance.
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| 19-06863-69 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network, Arlington, Texas | Comprehensive Healthcare Inspection Program | ||
1 The network director makes certain that the quality, safety, and value committee meets at least quarterly.
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2 The network director ensures the quality, safety, and value committee analyzes and reviews aggregated quality, safety, and value data.
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3 The network director makes certain that the quality management officer collects, analyzes, and acts upon Veterans Integrated Service Network peer review summary data as appropriate and monitors the quality management officer’s compliance.
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4 The chief medical officer confirms that facility service chiefs clearly define focused professional practice evaluation criteria in advance with licensed independent practitioners and monitors facility service chiefs’ compliance.
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5 The chief medical officer confirms that facility service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors clinical managers’ compliance.
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6 The network director makes certain that the Veterans Integrated Service Network safety and network emergency management committee sends an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement to leadership for review and approval and monitors the committee’s compliance.
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7 The quality management officer reviews Veterans Integrated Service Network facilities’ controlled substances inspection quarterly trend reports.
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| 19-00021-41 | Opportunities Missed to Contain Spending on Sleep Apnea Devices and Improve Veterans’ Outcomes | Audit | ||
1 Develop a mechanism to assess whether staffing levels within sleep medicine programs are sufficient for monitoring sleep apnea device use and conducting follow-ups with veterans.
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2 Ensure the Veterans Health Administration is leveraging existing technologies to make sure medical facilities are routinely monitoring veteran use of sleep apnea devices in a consistent and effective manner to more promptly identify individuals at risk of noncompliance with recommended therapies.
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3 Coordinate with the appropriate offices and services, including the Office of Procurement, Acquisitions, and Logistics, Prosthetic and Sensory Aids Service, sleep medicine, and the Veterans Health Administration National Infectious Diseases Service, to (a) assess the viability, potential patient care, and financial impact of an alternative to purchasing sleep apnea devices; (b) make and provide clear guidance on any changes to current Veterans Health Administration processes, including device returns, cleaning, and reissuance; and (c) designate an office with authority to ensure medical facilities implement any processes and recommendations from the assessment.
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| 19-00012-51 | Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures the Executive Committee of the Medical Staff reviews quarterly Peer Review Committee summary reports with trends and analysis of aggregate data and monitors the committee’s compliance.
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2 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
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3 The facility director makes sure the patient safety manager includes a review of relevant literature in the root cause analysis and monitors the patient safety manager’s compliance.
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4 The facility director confirms that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the committee’s compliance.
Closure Date:
5 The facility director ensures that clinical managers implement corrective actions and monitor for effectiveness when problems or opportunities for improvement are identified and monitors the clinical managers’ compliance.
Closure Date:
6 The chief of staff confirms that clinical service chiefs clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause that do not restrict the providers’ ability to practice independently for more than 30 days with providers and monitors the clinical service chiefs’ compliance.
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7 The associate director assures managers remove damaged wheelchairs from service and send them for repair or replacement and monitors managers’ compliance.
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8 The facility director makes certain that the facility quality manager ensures the Clinical and Performance Board reviews the monthly and quarterly controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.
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9 The facility director makes certain that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses of controlled substances and monitors inspectors’ compliance.
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10 The facility director ensures that a pharmacist reviews the Omnicell® override report for appropriateness and frequency as required and monitors the pharmacist’s compliance.
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11 The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
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12 The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
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13 The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
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| 19-00043-66 | Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
2 The facility director ensures that the patient safety manager completes the minimum requirement of eight root cause analyses each year and monitors compliance.
Closure Date:
3 The facility director ensures that the patient safety manager submits each root cause analysis to the National Center for Patient Safety within the required time frame and monitors compliance.
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4 The chief of staff ensures that service chiefs clearly define and communicate focused professional practice evaluation criteria in advance with providers and monitors service chiefs’ compliance.
Closure Date:
5 The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors compliance.
Closure Date:
6 The chief of staff ensures that ongoing professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
Closure Date:
7 The chief of staff ensures that service chiefs clearly define, share, and document in advance the expectations and outcomes for time-limited focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
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8 The associate director ensures that floors and ceilings tiles are repaired, cleaned, and maintained and window screens are replaced and monitors compliance.
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9 The associate director ensures expired medical supplies are removed from supply rooms and monitors compliance.
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10 The associate director ensures that VA police test panic alarms and evidence of testing is documented and monitors compliance.
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11 The facility director ensures that the comprehensive emergency management plan and its required elements are reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
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12 The facility director ensures an emergency operations plan is developed and reviewed annually.
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13 The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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14 The chief of staff makes certain that clinicians justify and document the reason for initiating the medication and monitors clinicians’ compliance.
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15 The chief of staff ensures that clinicians provide and document patient and/or caregiver education and evaluate understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
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16 The chief of staff ensures clinicians review and reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
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17 The facility director confirms that the Women Veterans Health Committee is comprised of required core members and monitors the committee’s compliance.
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18 The facility director requests the required waiver for urgent care clinic operations 24 hours a day, 7 days a week and continues such operations only if the waiver is approved.
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19 The facility director makes certain that a medical director for the urgent care center is formally appointed.
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20 The chief of staff ensures the urgent care center has a minimum of two registered nurses on staff during all hours of operation and monitors compliance.
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21 The chief of staff ensures that appropriate support services are in place during all hours of UCC operation and monitors compliance.
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