Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Memphis VA Medical Center, Memphis, Tennessee

Report Information

Issue Date
Report Number
14-04383-78
VISN
State
Arkansas
Mississippi
Tennessee
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 conducted a review of the Memphis VA Medical Center’s Community Based Outpatient Clinics (CBOCs) and other outpatient clinics to evaluate for safe, consistent, and high-quality health care. The review evaluated the clinics’ compliance with selected VHA requirements for alcohol use disorder, human immunodeficiency virus (HIV) screening, and outpatient documentation. We also randomly selected the Savannah, TN, CBOC as a representative site and evaluated the environment of care on November 4, 2014. OIG noted opportunities for improvement and made 14 recommendations in the following focused review areas: Alcohol Use Disorder, HIV Screening, 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 employees at the Savannah, TN, CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that safety inspections are performed on all the medical equipment at the Savannah, TN, CBOC in accordance with VA and Joint Commission standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hand hygiene compliance be monitored at the Savannah, TN, CBOC and reported to the Infection Control Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the Savannah, TN, CBOC to clearly identify all exits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Savannah, TN, CBOC and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Savannah, TN, CBOC to the parent facility.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that examination tables and curtains provide adequate privacy for women veterans at the Savannah, TN, CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Savannah, TN, CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that access to the information technology server closet at the Savannah, TN, CBOC is restricted and maintained according to information technology safety and security standards.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that access to the information technology server closet at the Savannah, TN, CBOC is documented consistently according to information technology safety and security standards.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.