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Combined Assessment Program Review of the Alaska VA Healthcare System, Anchorage, Alaska

Report Information

Issue Date
Report Number
13-00890-220
VISN
State
Alaska
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
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 122 employees. This review focused on eight operational activities. The facility complied with selected standards in the following four activities: (1) environment of care, (2) preventable pulmonary embolism, (3) continuity of care – fee basis, and (3) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishments were the Department of Defense/VA Joint Venture at Joint Base Elemendorf-Richardson and the facility’s telehealth program, both of which have improved access to care. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, and (4) long-term home oxygen therapy.

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 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 FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are consistently reported to the MEC.
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 quarterly trend reports summarize any discrepancies and problematic trends and identify potential areas for improvement.
No. 5
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 refresher training regarding problematic issues identified through external survey findings and other quality control measures.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that local policy related to the return of Green Sheets to the pharmacy is adhered to and that all elements required for the processing of prescriptions are present.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that documentation of CS inspector orientation, training, annual updates, and annual competency assessments are maintained.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors initial and date CS Inspecting Official Checklists, VA CS forms, and pharmacy activity logs.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
No. 10
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 in a timely manner.
No. 11
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.