We recommended that the System Director ensure that primary care providers follow established guidelines for referral of patients with chronic pain as required by VA policy.
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)
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the availability of personal protective equipment masks in all patient care areas and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
We recommended that employees secure medication carts when not in use, remove expired medications from patient care areas, and date multi-dose vials when opened and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
We recommended that a medical physicist complete and document inspections of computed tomography scanners following repair or modifications affecting dose or image quality and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/7/2017
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
We recommended that treatment teams follow up with patients at least four times during the first 30 days after discharge and that facility managers monitor compliance.