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Combined Assessment Program Review of the Alaska VA Healthcare System, Anchorage, Alaska

Report Information

Issue Date
Report Number
15-00618-02
VISN
State
Alaska
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
22
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 72 employees. This review focused on eight operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the continuity of care activity. The facility’s reported accomplishment was development of multiple partnerships with the community to ensure timely access to care for veterans in a highly rural state with limited health care resources. OIG made recommendations for improvement in the following eight activities, which includes the follow-up review area: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) mammography services, (5) suicide prevention program, (6) management of workplace violence, (7) Mental Health Residential Rehabilitation Treatment Program, and (8) follow-up on quality 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 and other key members required by local policy attend Quality Committee meetings or have a delegate represent them.
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 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 the facility analyze electronic health record quality data at least quarterly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a complete review of scanned documents to ensure retrievability, and quality assurance reviews on a sample of the scanned documents.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Chief of Staff complete an audit of all licensed independent practitioners’ privileges to ensure they are current and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the health care occupancy building has at least one fire drill during administrative hours per quarter and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the tuberculosis prevention plan policy to reflect current status of negative air exchange rooms in the primary care clinic and ensure employees are aware of procedures to care for infectious patients in lieu of negative air exchange rooms.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure correction of all deficiencies identified during annual physical security surveys.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently complete a physical count of all primary care clinics during the 1st month of each quarter and a physical count of 10 line items for all primary care clinics during the 2nd and 3rd months of each quarter and that the Controlled Substances Coordinator monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently complete pharmacy inspections on the same day initiated and that the Controlled Substances Coordinator monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility send written lay mammogram results to patients within 30 days of the procedure, that electronic health records reflect this, and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians communicate incomplete or “probably benign” results to patients within 14 days from availability of the results and document this in the electronic health record and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure all patients assessed to be at high risk for suicide have documented safety plans that specifically address suicidality and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure that patients and/or their families receive a copy of the safety plan and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team and a centralized disruptive behavior reporting and tracking system.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that monthly self-inspection documentation includes safety, security, and privacy.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Risk Manager continue the recently implemented peer review corrective action tracking process and ensure actions are completed and reported to the Peer Review Committee.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers consistently initiate Focused Professional Practice Evaluations for newly hired licensed independent practitioners at the time or before they begin providing patient care.