Combined Assessment Program Review of the VA Western New York Healthcare System, Buffalo, New York

Report Information

Issue Date
Report Number
13-00897-242
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
17
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 107 employees. This review focused on seven operational activities. The facility complied with selected standards in the environment of care activity. The facility’s reported accomplishments were a lean project success in wheelchair management, the offering of Kids’ Korner services to veterans, and the receipt of the Energy Star® Award for the past 5 years. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, (4) pressure ulcer prevention and management, (5) nurse staffing, and (6) construction safety.

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 FPPEs for newly hired licensed independent practitioners are initiated.
No. 3
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 and that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning includes image quality, linking of scanned documents to the correct record, and indexing the documents and that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 7
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 units that were outdated or otherwise discarded, the results of proficiency testing, and the results of inspections by government or private (peer) entities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is consistently reconciled; that hard copy orders for 5 randomly selected dispensing activities are validated in all non-pharmacy CS areas; and that at the Batavia pharmacy, audit trails for destruction of 10 randomly selected drugs are consistently verified.
No. 9
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff are consistent in pressure ulcer documentation of location, stage, size, characteristics, risk scale score, and date acquired and whether the wound has improved or deteriorated during the admission or at the time of discharge.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff consistently perform and document daily skin inspections and/or daily risk scales.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pressure ulcer education is provided to patients at risk for or with pressure ulcers and/or their caregivers.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive training on how to accurately document pressure ulcer findings and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nurse managers monitor the staffing methodology that was implemented in December 2012.
No. 17
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.