Combined Assessment Program Review of the Edward Hines, Jr. VA Hospital, Hines, Illinois

Report Information

Issue Date
Report Number
13-02315-332
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
5
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 220 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) quality management, (2) pressure ulcer prevention and management, and (3) nurse staffing. The facility’s reported accomplishments were launching the veterans mobile medical unit, achieving perfect accreditation with exemplary conformance from the Commission on Accreditation of Rehabilitation Facilities International, implementing the cochlear implant program, and implementing the da Vinci® Surgical System. OIG made recommendations for improvement in the following four activities: (1) environment of care, (2), medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, and (4) 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 ICC minutes reflect discussion of high-risk areas and actions implemented to address these areas.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inspectors consistently verify the three identified required drug destruction activities and that compliance be monitored.
No. 4
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.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that a contractor tuberculosis risk assessment is conducted prior to construction project initiation.