Breadcrumb

Combined Assessment Program Review of the Sioux Falls VA Health Care System, Sioux Falls, South Dakota

Report Information

Issue Date
Report Number
13-01674-256
VISN
State
South Dakota
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
3
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 155 employees. This review focused on six operational activities. The facility complied with selected standards in the following five activities: (1) quality management, (2) environment of care, (3) medication management – controlled substance inspections, (4) coordination of care – hospice and palliative care, and (5) nurse staffing. The facility’s reported accomplishments were pharmacy staff recognitions and collaboration efforts, pharmacy system cost savings and improvements, and the enteral feeding process redesign. OIG made recommendations for improvement in the pressure ulcer prevention and management activity.

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 acute care staff perform and document patient skin inspections and risk scale scores upon change in condition and/or at discharge and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff revise interprofessional treatment plans when there are risk level changes and that compliance be monitored.