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Community Based Outpatient Clinic Reviews at Marion VA Medical Center, Marion, IL

Report Information

Issue Date
Report Number
12-03851-117
VISN
State
Illinois
Indiana
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed the Marion VA Medical Center’s eight Community Based Outpatient Clinics (CBOCs) during the week of November 5, 2012. The purpose of the review was to assess whether the CBOCs provide veterans with consistent and safe high-quality health care. The review covered the clinical care components of women’s health cervical cancer screening and tetanus and pneumococcal vaccinations. We also randomly selected the Mayfield, KY and Vincennes, IN CBOCs for site visits and evaluated credentialing and privileging, environment of care, and emergency management processes. OIG noted opportunities for improvement and made a total of four recommendations to the Veterans Integrated Service Network (VISN) and facility managers.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent Facility Director ensures that each CBOC is assigned a WH Liaison and that the WH Liaison collaborates with the Women Veterans Program Manager.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians screen patients for tetanus vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians administer tetanus vaccinations when indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the service chiefs' documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Farmington and West Plains CBOCs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the PSB grants LIPs setting-specific privileges that are consistent with the services provided at the Farmington and West Plains CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the West Plains CBOC to clearly identify the location of fire extinguishers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire safety inspections are conducted annually at the West Plains CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes are strengthened to ensure patient privacy is maintained during examination at the Farmington CBOC.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that AEDs are checked daily at the West Plains CBOC, as required by facility policy.