Combined Assessment Program Review of the Spokane VA Medical Center, Spokane, Washington

Report Information

Issue Date
Report Number
13-00432-217
VISN
State
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
26
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 148 employees. This review focused on eight operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following three activities: (1) environment of care, (2) medication management – controlled substances inspections, and (3) preventable pulmonary embolism. The facility’s reported accomplishment was innovation in environment of care rounds. OIG made recommendations for improvement in the following six activities, including the follow-up review area: (1) quality management, (2) coordination of care – hospice and palliative care, (3) long-term home oxygen therapy, (4) nurse staffing, (5) construction safety, and (6) follow-up on coordination of care issue.

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 peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CACC 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 PCCT includes a dedicated administrative support person and a dedicated psychologist or other mental health provider.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the PCCT provide end-of-life training on a regular basis.
No. 5
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that HPC consults are acted upon within 7 days of the request.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed within 4 hours following an intervention and results documented in the EHR and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pain interventions identified on HPC inpatients' IPCs are consistently implemented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that IPCs specify responsible team members.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CLC social worker documents in the EHR that the CLC condolence letter was sent.
No. 11
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish an HRCT.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility conduct periodic, unscheduled onsite visits to the oxygen delivery contractor.
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 have active prescriptions and that patients are re-evaluated for home oxygen therapy annually 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 high-risk home oxygen patients are identified.
No. 16
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. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology that was implemented in August 2011.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that documentation of construction site inspections includes all required elements.
No. 22
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 ICC minutes.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CSC minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that when required, continuous negative air pressure is achieved prior to initiating work at a construction site.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that physician orders and discharge summaries are consistent.