Combined Assessment Program Review of the Boise VA Medical Center, Boise, Idaho

Report Information

Issue Date
Report Number
13-04241-78
VISN
State
Idaho
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
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 142 employees. This review focused on seven operational activities. The facility complied with selected standards in the environment of care activity. The facility’s reported accomplishment was an all-terrain vehicle experience for veterans with disabilities. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) medication management, (3) coordination of care, (4) nurse staffing, (5) pressure ulcer prevention and management, and (6) community living center resident independence and dignity.

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 code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Invasive Procedure Committee includes the COS as a member, monitors surgery performance improvement activities, and documents its review of surgical deaths.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the review of EHR quality includes most services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that discharge instructions are consistent with patients¿ identified post-discharge needs and include all elements required by VHA policy and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility have a Veterans Health Education Coordinator and an active Veterans Health Education Committee.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of the facility expert panel receive the required training prior to the next annual staffing plan reassessment.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SCC minutes include analysis of pressure ulcer data and that the SCC routinely reports program data to facility executive leadership.
No. 10
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 pressure ulcer location and stage for all patients with pressure ulcers and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish ongoing staff pressure ulcer education requirements and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents¿ care plans or document reasons for discontinuing or not providing restorative nursing services and that compliance be monitored.