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Healthcare Inspection – Alleged Short-Stay Rehabilitation Unit Concerns, Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Report Information

Issue Date
Report Number
15-01445-400
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to an anonymous complaint concerning the Short-Stay Rehabilitation Unit (Valor Center) at the Tuscaloosa VA Medical Center (facility) Tuscaloosa, AL. We did not substantiate that the facility did not have a screening process for prospective Valor Center patients or that patients were inappropriately admitted to the Valor Center. However, we determined that the Valor Center prospective patient screening practices at the time of our site review were not in compliance with the facility’s Community Living Center and the Valor Center admission policies. Also, while not an allegation, we determined that pre-admission consults with the facility physiatrist were not documented in patients’ electronic health records. We did not substantiate that staff who point out potential wrongdoing were intimidated, transferred, harassed, or terminated. We substantiated that the Associate Chief of Staff for Geriatrics and Extended Care Services was the decision maker for admissions to the Valor Center and that performance-based pay was connected to the Valor Center’s average daily bed census. However, we determined that neither was against Veterans Health Administration policy, and the performance pay incentive did not influence the Associate Chief of Staff’s Valor Center admission decisions. We substantiated poor hand-off communication for newly admitted patients. We made three recommendations. The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan.

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 Director ensure that the assessments for patients screened for admission by the facility physiatrist consultant are documented in the electronic health records.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure Valor Center screening and admission policies are consistent with Valor Center practices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that all relevant staff are notified of planned Valor Center admissions to allow staff sufficient time to make appropriate plans for required care and services.