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Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey

Report Information

Issue Date
Report Number
15-00616-543
VISN
State
New Jersey
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
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 271 employees. This review focused on nine operational activities. The facility complied with selected standards in the following two activities (1) computed tomography radiation monitoring and (2) surgical complexity. The facility’s reported accomplishment was the GetWell Network. 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) emergency airway management, and (7) 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 when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management are granted privileges to perform the procedure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies and include corrective actions and tracking of actions to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees initiate corrective actions when sterile supply room temperature and/or humidity values are out of range and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace damaged paper towel dispensers in patient and public restrooms and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged patient equipment and furnishings or remove them from service and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure crash cart logs contain the correct lock number and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees follow up with inpatients who would like to discuss creating, changing, and/or revoking advance directives to ensure the discussion takes place and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have all required competency elements prior to being assigned coverage.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure video laryngoscopes are available in all designated locations at the Lyons campus and monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that the Domiciliary Care for Homeless Veterans Program has signage alerting veterans and visitors of closed circuit television recording.