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Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio

Report Information

Issue Date
Report Number
13-00275-149
VISN
State
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
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 258 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) environment of care and (2) nurse staffing. The facility’s reported accomplishment was the success of its bed turn-around time team. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, (4) long-term home oxygen therapy, and (5) preventable pulmonary embolism.

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 FPPEs for newly hired licensed independent practitioners are consistently completed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
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 actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution for Inpatient Evaluation Center data, utilization management, outcomes from resuscitation, copy and paste, and blood/transfusion reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that two transfers of CS from one storage area to another are validated and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inspectors sign and initial inspection documents in accordance with local policy.
No. 8
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that interdisciplinary care plans for HPC inpatients include all elements required by local policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate internal protected peer review for the three identified patients and complete any recommended review actions.