Breadcrumb

Combined Assessment Program Review of the Charles George VA Medical Center, Asheville, North Carolina

Report Information

Issue Date
Report Number
13-00276-135
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
15
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 119 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) medication management – controlled substances inspections, (2) nurse staffing, and (3) preventable pulmonary embolism. The facility’s reported accomplishments were a system redesign project to improve the appropriateness of admissions to vascular surgery and oncology inpatient beds and to reduce avoidable bed days of care and diversion hours and the initiation of multiple communication and transparency activities to improve employee satisfaction. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) coordination of care – hospice and palliative care, (4) long-term home oxygen therapy, and (5) construction safety.

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 processes be strengthened to ensure that actions from PRs are consistently completed and reported to the PR Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the local observation bed policy be revised to include all required elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing and of PRs when transfusions did not meet criteria.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that documentation for blood product transfusions includes applicable laboratory/clinical results post-transfusion and the assessment of outcome.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution in utilization management, resuscitation, and blood/transfusion utilization reviews.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to housekeeping deficiencies identified during EOC rounds are tracked to closure.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions are implemented to address high-risk areas and that Infection Control Committee minutes document those actions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that expired commercial supplies are removed from sterile storage rooms and treatment areas.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that After-Installation Checklists are completed for all ceiling lifts in the PT/OT/KT clinic areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that damaged chairs in the PT/OT/KT clinic areas are repaired or removed from service.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that home oxygen program patients receive a timely annual re-evaluation after the first year.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.