Combined Assessment Program Review of the VA Maine Healthcare System, Augusta, Maine

Report Information

Issue Date
Report Number
15-00605-544
VISN
State
Maine
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
19
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 43 employees. This review focused on eight operational activities. The facility complied with selected standards in the computed tomography radiation monitoring activity. The facility’s reported accomplishments were a first time 3-year accreditation with exemplary conformance from the Commission on Accreditation of Rehabilitation Facilities for the Acceptance and Commitment Therapy for Pain Program and being one of five beta test sites for Maine’s prescription monitoring program. OIG made recommendations for improvement in the following seven activities: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) advance directives, (6) surgical complexity, and (7) emergency airway management.

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 chair or co-chair the Performance Improvement Board.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassess observation criteria and utilization.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Special Care Unit Committee review each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently include most services in the review of electronic health record quality.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy 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, a complete review of scanned documents to ensure readability and retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas are clean and damaged wall surfaces are repaired and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the walkway from the handicapped parking area to the main entrance is repaired.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees promptly remove expired or undated medications from patient care areas and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a written policy for safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility create/designate a committee to oversee consult management.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently correctly post patients' advance directives status and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that special care unit nurses have 12-lead electrocardiogram competency assessment and validation completed and documented.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include the availability of portable video laryngoscopes, the use of a device to confirm endotracheal tube placement in conjunction with auscultation, and a plan for managing the difficult airway.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure completion of initial assessments for emergency airway management competency prior to the clinicians providing coverage.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.