Date Issued
|
Report Number
16-00552-341
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/19/2018
We recommended that facility managers ensure floors and rolling equipment in patient care areas are clean and in good repair and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/7/2018
We recommended that the facility review quality assurance data for the anticoagulation management program monthly at Pharmacy and Therapeutics Committee meetings and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulants.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/6/2018
We recommended that the laboratory director develop and implement a process to ensure employee competency for point-of-care testing with glucometers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that the laboratory director ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/12/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/7/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.