Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern California Health Care System, Mather, California

Report Information

Issue Date
Report Number
14-00937-31
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
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 VA Northern California 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 Fairfield CBOC, Travis Air Force Base, CA; Martinez CBOC, Martinez, CA; and Redding CBOC, Redding, CA, for site visits during the week of September 15, 2014, to evaluate the environments of care. OIG noted opportunities for improvement and made eight 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 processes are improved to ensure compliance with requirements for hazardous materials, including tracking of hazardous materials inventories at the Martinez CBOC, reviewing these inventories twice within a 12-month period at the Martinez and Redding CBOCs, and training Martinez CBOC staff to ensure access to the electronic version of the material safety data sheets.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Fairfield and Martinez CBOCs to the parent facility or contracted processing facility, by securing patient data in the Health Education Room, and through the use of privacy screens on computer monitors at the Martinez Primary Care check-in desk.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility’s Emergency Management Committee includes the CBOC in required education, training, planning, and participation leading up to the annual disaster exercise and evaluates the Fairfield, Martinez, and Redding CBOCs’ emergency preparedness activities and participation in annual disaster exercises.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 6
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. 7
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff provide and document medication counseling/education as required.