Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pacific Islands Health Care System, Honolulu, Hawaii

Report Information

Issue Date
Report Number
15-00180-538
VISN
State
American Samoa
Guam
Hawaii
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 VA Pacific Islands Health Care System’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 care, human immunodeficiency virus (HIV) screening, outpatient documentation, and outpatient lab results management. We also randomly selected the American Samoa VA Clinic, Pago Pago, AS, as a representative site and evaluated the environment of care on July 28, 2015. OIG noted opportunities for improvement and made 14 recommendations in the following focused review areas: Alcohol Use Disorder Care, HIV Screening, Outpatient Lab Results 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 managers maintain a clean and functioning environment of care at the American Samoa VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the American Samoa VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that safety data sheets are readily available to staff at the American Samoa VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hand hygiene compliance is monitored at the American Samoa VA Clinic and reported to the Infection Control Committee.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious) waste at the American Samoa VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that written procedures are available and staff are trained to properly disinfect non-critical medical equipment as required at the American Samoa VA Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the information technology server closet at the American Samoa VA Clinic is maintained according to information technology safety and security standards.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that panic alarms are installed and tested, and testing is documented in all high-risk areas at the American Samoa VA Clinic.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the American Samoa VA Clinic receive regular information/updates on their responsibilities in emergency response operations.
No. 10
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 12
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. 13
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.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.