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Community Based Outpatient Clinic and Primary Care Clinic Reviews at South Texas Veterans Health Care System, San Antonio, Texas

Report Information

Issue Date
Report Number
14-00912-192
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed the Community Based Outpatient Clinics (CBOCs) and primary care clinics (PCCs) of the South Texas Veterans Health Care System. The purpose of the review was to determine whether the CBOCs and PCCs provide safe, consistent, and high-quality health care for our veterans. The review covered the clinical care components of alcohol use disorder and medication management and evaluated if processes were in place for designated women’s health providers to maintain proficiency in women’s health. We also randomly selected the Beeville CBOC, Beeville, TX; Frank M. Tejeda Satellite CBOC, San Antonio, TX; and San Antonio Area Primary Care Network CBOC, San Antonio, TX, for site visits during the week of May 5, 2014, to evaluate the environments of care. OIG noted opportunities for improvement and made six recommendations in the following reviews: Alcohol Use Disorder, Medication Management, and Environment of Care.

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 external signage clearly identifies the building as a VA CBOC at the Beeville CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers maintain clean carpets at the Frank M. Tejeda Satellite CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all identified environment of care deficiencies at the Beeville and San Antonio Primary Care Network CBOCs are reported to and tracked by the parent facility's Environment of Care Committee until resolution.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document the evaluation of patient's level of understanding for the flouroquinolone medication education.