Combined Assessment Program Review of the VA Pacific Islands Health Care System, Honolulu, Hawaii

Report Information

Issue Date
Report Number
15-00626-28
VISN
State
Hawaii
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
18
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 166 employees. This review focused on eight operational activities. The facility complied with selected standards in the following five activities: (1) medication management – controlled substances inspection program, (2) computed tomography radiation monitoring, (3) mammography services, (4) emergency airway management, and (5) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishment was Office of Rural Health projects to improve access to evidenced-based care for veterans with post-traumatic stress disorder who live in rural communities. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) environment of care, and (3) suicide prevention 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 the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee meeting minutes consistently document tracking of identified deficiencies to closure and that monthly meetings consistently include community based outpatient clinic representation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Infection Control Committee meeting minutes consistently reflect discussion of identified high-risk areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure furnishings and equipment in patient care areas are in good repair and have upholstery that is easily cleaned.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees routinely inspect Center for Aging privacy and shower curtains and initiate actions to replace those with stains.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure heavy-use public restrooms in the ambulatory care center have frequent inspections and receive cleaning as needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers initiate corrective actions to repair the ceiling leak in the ambulatory care center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees store clean and dirty items separately and promptly remove cardboard boxes from storage areas and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure negative air pressure systems are functional in all designated rooms and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all chairs in the acute psychiatry unit 3B2 dining/activity room are weighted.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility’s Emergency Operations Plan include all required Joint Commission elements.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an adequate back-up plan for a Suicide Prevention Coordinator.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and for identifying and tracking patients who are at high risk for suicide
No. 14
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a process to follow up on patients who miss MH appointments and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians include patients and/or their families in safety plan development and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that mental health providers ensure outpatients flagged as high risk for suicide have a suicide prevention safety plan completed within the first 72 hours of contact and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that mental health providers ensure outpatients flagged as high risk for suicide are evaluated at least four times within 30 days of flag placement if an outpatient or at least four times within 30 days of discharge from the inpatient psychiatric unit and that facility managers monitor compliance.