Date Issued
|
Report Number
19-00014-33
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
to Veterans Health Administration (VHA)
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.
No. 4
to Veterans Health Administration (VHA)
The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.
No. 5
to Veterans Health Administration (VHA)
The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.
No. 6
to Veterans Health Administration (VHA)
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.
No. 7
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.
No. 8
to Veterans Health Administration (VHA)
The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/2/2021
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 9/16/2020
The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.