Date Issued
|
Report Number
15-00408-204
All Reports
Date Issued
|
Report Number
14-02890-169ccc
Date Issued
|
Report Number
15-04681-228
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that providers assign the proper inpatient/outpatient setting and urgency of consults in the electronic health record.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff take action within 7 days of a consult request or sooner if clinically indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff timely close or discontinue consults.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/4/2017
We recommended that the Facility Director ensure that staff conduct a review on the quality and timeliness of the cardiology care for Patient 1 as discussed in the report, and take action if appropriate.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/6/2017
We recommended that the Facility Director ensure that staff monitor and address the care needs of patients on the Homemaker/Home Health Aide services electronic wait list.
Date Issued
|
Report Number
16-04882-216
Date Issued
|
Report Number
14-02890-409
Date Issued
|
Report Number
14-02890-116
Date Issued
|
Report Number
14-02890-93
Date Issued
|
Report Number
14-03368-97
Date Issued
|
Report Number
14-02890-126
Date Issued
|
Report Number
14-02890-129
Date Issued
|
Report Number
14-02890-112
Date Issued
|
Report Number
14-02890-96
Date Issued
|
Report Number
14-02890-127bbb
Date Issued
|
Report Number
14-02890-104
Date Issued
|
Report Number
14-02890-110
Date Issued
|
Report Number
16-02094-219
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/18/2017
We recommended that the Facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.
Date Issued
|
Report Number
15-01325-205
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director ensure that program staff coordinate mental health appointments, including verifying the necessity, between facility providers and assigned community nursing home physicians prior to scheduling.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/20/2017
We recommended that the Facility Director ensure clinical staff report suspected elder abuse within the required timeframe and document the reporting in the patient’s electronic health record.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/29/2017
We recommended that the Facility Director ensure Non-VA Care Coordination staff timely deliver authorizations for consulted services to contracted community nursing home staff and that facility scheduling staff recognize when patients reside in a community nursing home and coordinate appointments with program or contracted community nursing home staff to ensure timely response to consults.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/24/2018
We recommended that the Facility Director require program registered nurses and social workers consistently conduct monthly or quarterly follow-up visits and ensure timely resolution of patient care needs identified in these visits.
Date Issued
|
Report Number
16-05353-220
Date Issued
|
Report Number
16-00571-207
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data twice a year and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility clinical managers ensure peer reviewers consistently document their use of at least one of the important aspects of care and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
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. 4
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that the Patient Safety Manager enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/24/2017
We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/17/2017
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: 11/17/2017
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that facility managers ensure all employees receive additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/23/2017
We recommended that Residential Recovery Center employees perform and document contraband inspections and rounds of public spaces and that managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.
Date Issued
|
Report Number
16-00354-201
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/14/2017
We recommended the System Director ensure Mental Health schedulers consistently make direct contact with patients prior to scheduling appointments and that compliance is monitored for a minimum of three months.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/29/2017
We recommended the System Director ensure training and competencies are documented, complete, and up to date for all staff responsible for scheduling Mental Health appointments.