Nuestra Clinica Del Valle, Inc.
HCO ID: 241076
801 W. 1st Street
San Juan , TX, 78589
Activity as of:
9/27/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/27/2014
9/14/2017
9/14/2017
 
Laboratory
Accredited
4/8/2017
4/7/2017
4/7/2017
 
6/14/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/27/2014
9/26/2014
9/26/2014
 
Laboratory
Accredited
4/8/2017
4/7/2017
4/7/2017
 
4/12/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/27/2014
9/26/2014
9/26/2014
 
Laboratory
Accredited
8/29/2015
4/7/2017
4/7/2017
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/27/2014
9/26/2014
9/26/2014
 
Laboratory Accreditation Program
Accredited
8/29/2015
8/28/2015
8/28/2015
 
10/2/2015
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/27/2014
9/26/2014
9/26/2014
 
Laboratory Accreditation Program
Accredited
10/26/2013
8/28/2015
8/28/2015
 
12/18/2014
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/27/2014
9/26/2014
9/26/2014
 
Laboratory Accreditation Program
Accredited
10/26/2013
10/25/2013
10/25/2013
 
10/8/2014
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
10/27/2011
9/26/2014
9/26/2014
 
Laboratory Accreditation Program
Accredited
10/26/2013
10/25/2013
10/25/2013
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
10/27/2011
10/26/2011
10/26/2011
 
Laboratory Accreditation Program
Accredited
10/26/2013
10/25/2013
10/25/2013
 
11/6/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
10/27/2011
10/26/2011
10/26/2011
 
Laboratory Accreditation Program
Accredited
10/29/2011
10/25/2013
10/25/2013
 
8/23/2012
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
10/27/2011
10/26/2011
10/26/2011
 
Pathology and Clinical Laboratory
Accredited
10/29/2011
10/28/2011
10/28/2011
 
12/14/2011
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
6/23/2010
10/26/2011
10/26/2011
 
Pathology and Clinical Laboratory
Accredited
10/31/2009
10/28/2011
10/28/2011
 
10/28/2011
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
6/23/2010
10/26/2011
10/26/2011
 
Pathology and Clinical Laboratory
Accredited
10/31/2009
10/30/2009
10/30/2009
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
6/23/2010
12/19/2008
12/7/2009
 
Pathology and Clinical Laboratory
Accredited
10/31/2009
10/30/2009
10/30/2009
 
5/19/2010
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Conditional Accreditation
12/20/2008
12/19/2008
12/7/2009
 
Pathology and Clinical Laboratory
Accredited
10/31/2009
10/30/2009
10/30/2009
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections.
  • The organization effectively manages its programs, services, or sites.
  • The organization evaluates the effectiveness of its Emergency Management Plan.
  • The organization uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
1/26/2010
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Conditional Accreditation
12/20/2008
12/19/2008
12/19/2008
 
Pathology and Clinical Laboratory
Accredited
10/31/2009
10/30/2009
10/30/2009
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections.
  • The organization effectively manages its programs, services, or sites.
  • The organization evaluates the effectiveness of its Emergency Management Plan.
  • The organization uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
12/29/2009
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Conditional Accreditation
12/20/2008
12/19/2008
12/7/2009
 
Pathology and Clinical Laboratory
Accredited
9/29/2007
10/30/2009
10/30/2009
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections.
  • The organization effectively manages its programs, services, or sites.
  • The organization evaluates the effectiveness of its Emergency Management Plan.
  • The organization uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
11/3/2009
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Conditional Accreditation
10/22/2005
12/19/2008
12/19/2008
 
Pathology and Clinical Laboratory
Accredited
9/29/2007
10/30/2009
10/30/2009
 

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • As part of its emergency management activities, the organization prepares to respond to an influx, or the risk of an influx, of infectious patients.
  • Based on risks, the organization establishes priorities and sets goals for preventing the development of health care-associated infections within the organization.
  • Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
  • Conduct a 'time out' immediately before starting the procedure as described in the Universal Protocol
  • Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.
  • Informed consent is obtained.
  • Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
  • The infection control program evaluates the effectiveness of the infection control interventions and, as necessary, redesigns the infection control interventions.
  • The infection control program identifies risks for the acquisition and transmission of infectious agents on an ongoing basis.
  • The leaders measure and assess the effectiveness of the performance improvement and safety improvement activities.
  • The organization collects data to monitor its performance.
  • The organization regularly tests its emergency management plan.
  • The risk of development of a health care-associated infection is minimized through an organizationwide infection control program.
  • There is a process for ensuring the competence of all practitioners permitted by law and the organization to practice independently.
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
10/22/2005
12/19/2008
12/19/2008
 
Pathology and Clinical Laboratory
Accredited
9/29/2007
9/28/2007
9/28/2007
 
3/19/2009
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
10/22/2005
12/19/2008
12/19/2008
 
Pathology and Clinical Laboratory
Accredited
9/29/2007
9/28/2007
9/28/2007
 
2/11/2009
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/20/2003
10/21/2005
10/21/2005
 
Pathology and Clinical Laboratory
Accredited
9/20/2003
9/28/2007
9/28/2007
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Ambulatory Care
Accredited
9/20/2003
12/19/2008
12/19/2008
 
Pathology and Clinical Laboratory
Accredited
9/20/2003
9/28/2007
9/28/2007