Breadcrumb

Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey

Report Information

Issue Date
Report Number
13-00886-210
VISN
State
New Jersey
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
18
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 323 employees. This review focused on eight operational activities. The facility complied with selected standards in the construction safety activity. The facility’s reported accomplishments were the hospice and palliative care memorial tribute book, simulation and experiential education, and the Quiet Campaign. OIG made recommendations for improvement in the following seven activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) long-term home oxygen therapy, (6) nurse staffing, and (7) 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 the local observation bed policy be revised to include all required elements.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes and that code sheets are scanned into the EHRs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that sensitive patient information is secured on computer screens in the ED.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that medical equipment in the ED is terminally cleaned after patient discharge.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that supplies and equipment in the East Orange PT clinic are properly stored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility policy be amended to address that the CS Coordinator PD or functional statement must include CS inspection and coordination, to include that the CS Coordinator must have complete understanding of CS policies and VHA inspection process, and to include requirements for new CS inspector orientation and annual training thereafter.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 12
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
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 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 home oxygen program patients deemed to be high risk have fire risk assessments completed and that 3-month follow-up evaluations are completed for all home oxygen program patients.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that unit 9A's expert panel include all required members.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensure 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 managers initiate protected peer review for the identified patient and complete any recommended review actions.