Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon

Report Information

Issue Date
Report Number
14-02072-283
VISN
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a review 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 172 employees. This review focused on eight operational activities. The facility complied with selected standards in the management of workplace violence activity. The facility’s reported accomplishment was the development of the Veterans Day Respite program, which provides socialization to and assists with community integration of veterans living in rural areas and provides support for their caregivers. OIG made recommendations for improvement in the following seven activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspection program, (4) continuity of care, (5) management of test results, (6) suicide prevention program and (7) Mental Health Residential Rehabilitation Treatment Program.

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 the facility implement a quality control policy for scanning that includes all required elements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that infection prevention educational materials are available for eye clinic patients, visitors, and family members.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that dirty items in the eye clinic are not stored in patient care areas 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 employees reprocess ophthalmology pachymetry probes in accordance with manufacturer's instructions and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility policy be amended to include that Controlled Substances Coordinators must be free from conflicts of interest, that controlled substances inspectors must be appointed in writing, and that annual updates for controlled substances inspectors include problematic issues identified through external survey findings and other quality control measures.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop instructions for inspections of automated dispensing machines.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the medical information from non-VA hospitalizations is consistently scanned into the electronic health records and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that licensed independent practitioners are notified of critical laboratory test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that safety plans contain documentation of assessment of available lethal means and ways to keep the environment safe 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 patients and/or their families receive a copy of the safety plan and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that written agreements acknowledging resident responsibility for medication security are in place in the domiciliary and the Domiciliary Care for Homeless