Community Based Outpatient Clinic Reviews at Robley Rex VA Medical Center, Louisville, KY

Report Information

Issue Date
Report Number
13-00026-177
VISN
State
Indiana
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed the Robley Rex VA Medical Center’s eight Community Based Outpatient Clinics (CBOCs) during the week of February 25, 2013. 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 Carroll County, Carrollton, KY, and Scott County, Scottsburg, 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 seven 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 a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the allotted timeframe and that notification is documented in the EHR.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that clinicians administer pneumococcal 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 pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that FPPEs are initiated for all providers who request new privileges at the Scott County CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure annual fire drills are completed at the Carroll County and Scott County CBOCs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all identified EOC deficiencies at the Carroll County and Scott County CBOCs are tracked and trended until corrected.