Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts

Report Information

Issue Date
Report Number
15-00598-446
VISN
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
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 32 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) coordination of care and (2) emergency airway management. The facility’s reported accomplishments were first responder training and the hospice unit. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) medication management, (4) medication management – controlled substances inspection program, and (5) 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 facility managers review privilege forms annually and document the review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Medical Emergency Committee review each code episode.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Accident Review Board Committee share patient handling injury data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy/process for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility clean and/or repair soiled and/or damaged wheelchairs in patient care areas or remove them from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Controlled Substances Coordinator provide quarterly trend reports to the Facility Director.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently inspect all required non-pharmacy areas with controlled substances and that the Controlled Substances Coordinator monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Controlled Substances Coordinator sufficiently rotates controlled substances inspectors in inspection assignments and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors complete inspections on the same day initiated and that the Controlled Substances Coordinator monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the controlled substances inspection program has adequate oversight and complies with Veterans Health Administration policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Domiciliary Care for Homeless Veterans Program employees conduct and document monthly self-inspections and that program managers monitor compliance.