Date Issued
|
Report Number
17-01758-104
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/18/2018
The Chief of Staff ensures that clinical managers communicate to the Peer Review Committee all completions of individual improvement actions and monitors managers’ compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data with the frequency required by facility policy and monitors the managers’ compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff requires clinicians to ensure patients with newly prescribed warfarin have international normalized ratio measurements taken within 7 days of warfarin initiation, and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff requires clinical managers to complete competency assessments annually for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Chief of Staff ensures clinicians consistently include identification of the receiving provider in transfer documentation and monitors the clinicians’ compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures the Chesapeake community based outpatient clinic panic alarms are tested monthly and monitors compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures storage carts and shelves at the Chesapeake Community Based Outpatient Clinic have solid bottom shelves and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures locked mental health unit panic alarm testing includes documentation of VA Police response time and monitors compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training for identification and correction of environmental hazards and proper use of the Mental Health Environment of Care Checklist and monitors compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures providers include a history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and monitors providers’ compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures that physicians who perform or assist with moderate sedation procedures receive training for the provision of moderate sedation care prior to being re-privileged and that training is documented and monitors compliance with training and documentation.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Facility Director ensures that the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates processes into the facility’s quality improvement program with documentation of these processes in the facility’s executive-level committee meeting minutes and monitors compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and submits exclusionary criteria exemption requests when a community nursing home meets the threshold of four or more deficiencies and monitors the team’s compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors social workers’ and registered nurses’ compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures that Domiciliary Care for Homeless Veterans Program, general domiciliary, and Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees conduct and document daily resident room inspections for unsecured medications and monitors employees’ compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 7/25/2018
The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.