Combined Assessment Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington

Report Information

Issue Date
Report Number
14-02078-38
VISN
State
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
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 63 employees. This review focused on eight operational activities. The facility complied with selected standards in the medication management – controlled substances inspection program activity. The facility’s reported accomplishment was its Life Goals Project, a veteran-centered approach to individualized care based on what matters to the veteran. OIG made recommendations for improvement in the following seven activities: (1) quality management, (2) environment of care, (3) continuity of care, (4) management of test results, (5) suicide prevention program, (6) management of workplace violence, 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 Quality Management Board meet at least quarterly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Peer Review Committee consistently submit quarterly summary reports to the Executive Committee of the Medical Staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluations for newly hired licensed independent practitioners are initiated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Executive Committee of the Medical Staff discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all specialty clinic employees receive annual bloodborne pathogens training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that eye clinic exam/procedure room sinks have foot controls, long-blade handles, or automatic no touch sensors.
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 record 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 clinicians document acknowledgement of their patients¿ recent non-VA hospitalizations.
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 abnormal Pap smear results/values within the expected timeframe and that notification is documented in the electronic health record 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 all patients are notified of normal lab results/values and radiology results within the expected timeframe and that notification is documented in the electronic health record.
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 all employees receive Level 1 training and that the training be documented in employee training records.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that residential rehabilitation unit employees perform and document daily inspections for unsecured medications and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a process be in place to alert residential rehabilitation unit employees when alarmed doors that are not considered main points of entry are opened from the inside and that the process be tested regularly.