Date Issued
|
Report Number
17-01741-58
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data quarterly and monitors the managers’ compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Associate Director for Patient Care Services ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Associate Director ensures quality assurance data for the anticoagulation management program are reviewed at the Pharmacy and Therapeutics Committee and monitors compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Chief of Staff ensures clinicians provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures clinicians obtain required laboratory tests prior to initiating anticoagulant medications and monitors the clinicians’ compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Associate Director ensures all required elements specific to anticoagulation management are included in competency assessments for all employees actively involved in the anticoagulant program and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee assigned these responsibilities and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Associate Director for Patient Care Services ensures providers consistently document patient or surrogate informed consent and patient medical and behavioral stability and identify transferring providers or designees for patients transferred out of the facility and monitors providers’ compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Associate Director for Patient Care Services ensures that, for inter-facility transfers, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures environment of care inspections are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures core team members consistently participate in environment of care rounds and attendance is documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures that in patient care areas, floors and rolling equipment are clean, nourishment kitchen ice machines are clean, and damaged furniture is repaired or removed from service and monitors compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures outdated supplies are removed from the Santa Fe VA Clinic and monitors compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Assistant Director ensures facility managers complete a physical security assessment for the locked geriatric mental health unit.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, to include the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures that providers include the accurate name of the provider performing the procedure on the informed consent and monitors providers’ compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures the privileged providers performing the procedure participate in the timeout process prior to moderate sedation procedures and monitors providers’ compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by all required disciplines and monitors compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.