Date Issued
|
Report Number
15-04697-105
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data biannually and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/21/2017
We recommended that Physician Utilization Management Advisors document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that the facility consistently take actions when data analyses indicate problems or opportunities for improvement and evaluate them for effectiveness in committee reviews, utilization management, and root cause analyses and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that the facility conduct an annual infection prevention risk assessment.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/10/2016
We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that the facility revise its policy for temporary bed locations to include priority placement for inpatient beds given to patients in temporary bed locations, upholding the standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that sending nurses document transfer assessments and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that clinicians consistently place flags in the electronic health records of patients identified as high risk for suicide and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 9/14/2016
We recommended that clinicians not place flags in the electronic health records of patients identified as moderate or low risk for suicide and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/31/2017
We recommended that clinicians include the identification of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility managers ensure electronic health record quality reviews include a representative sample of charts from each service or program.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended that facility managers ensure all non-hospice and palliative care clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/14/2016
We recommended that facility managers establish a process to track and document hospice and palliative care consults that are not acted upon within 7 days of the request.