Combined Assessment Program Review of the Salem VA Medical Center, Salem, Virginia

Report Information

Issue Date
Report Number
13-00889-206
VISN
State
Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
23
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 157 employees. This review focused on eight operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) medication management – controlled substances inspections and (2) coordination of care – hospice and palliative care. The facility’s reported accomplishment was the Improving Our Work Is Our Work initiative to identify organizational improvement activities. OIG made recommendations for improvement in the following six activities and follow-up area: (1) quality management, (2) environment of care, (3) long-term home oxygen therapy, (4) nurse staffing, (5) preventable pulmonary embolism, (6) construction safety, and (7) follow-up on emergency/urgent care operations issues.

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 the Critical Care Committee reviews each CPR episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility continue to monitor the EHR copy and paste function.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 4
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 number of transfusions and number reviewed for appropriateness, the results of proficiency testing, PRs when transfusions did not meet criteria, and results of inspections by government or private (peer) entities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that when data analyses indicate problems or opportunities for improvement, actions taken are consistently followed to resolution in utilization management, outcomes of resuscitation, and RAI/MDS quality reviews.
No. 6
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 identified deficiencies are tracked to closure.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Infection Control Committee actions are implemented to address high-risk areas and that committee minutes document those actions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Infection Control Committee minutes consistently reflect analysis of surveillance activities.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that floors, ventilation system outlets, and horizontal surfaces in patient care areas are clean and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that mattresses, pillows, geri-chairs, and treatment table mats are routinely inspected and that those with compromised surfaces are repaired or removed from service.
No. 11
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 patient care areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that women's health clinic exit signage is properly oriented and visible from all hallways.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
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 receive education on the hazards of smoking while oxygen is in use at the required intervals and that the education be documented.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Home Respiratory Care Committee evaluates patient safety-related events for home oxygen patients and planning for patients discontinued from home oxygen therapy to determine whether additional actions are warranted.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of unit 4H/4J's expert panel receive the required training prior to the next annual staffing plan reassessment.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers complete protected PR for the identified patient and any recommended review actions.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Construction Safety Committee oversees construction and renovation activities, that the policy outlining the responsibilities of the committee is followed, that the multidisciplinary team conducts site visits at the specified frequency, and that meeting minutes contain discussion of site conditions and any required follow-up.
No. 19
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.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive initial and/or refresher construction safety training and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that ED staff document discharge instructions and evaluate patient and/or caregiver understanding of the discharge instructions.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the process for requesting and granting ED staff privileges complies with VHA policy.