Combined Assessment Program Follow-Up Review of the VA St. Louis Health Care System, St. Louis, Missouri

Report Information

Issue Date
Report Number
15-00075-87
VISN
State
Missouri
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted this follow-up review to assess the status of action plans in response to the recommendations from our prior Combined Assessment Program review and to re-evaluate selected health care facility operations, focusing on patient care quality and the environment of care. This review focused on nine operational activities. For the following seven activities, we made no new recommendations and where applicable, closed recommendations when actions plans were completed: (1) quality management, (2) medication management, (3) coordination of care, (4) magnetic resonance imaging safety, (5) acute ischemic stroke care, (6) surgical complexity, and (7) emergency airway management. OIG made new recommendations for improvement in the following two activities (1) environment of care and (2) 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 facility managers ensure access to exits is unrestricted and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all nurse call system alarms are functioning and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure emergency response medications and equipment are available for immediate use in patient care areas and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure electrical power strips are not plugged into other power strips and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure crash carts using electrical power strips have those strips permanently attached.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas do not contain portable space heaters and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair or replace the uneven and buckling flooring in the combined Domiciliary and Substance Abuse Residential Rehabilitation Treatment Program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure compliance with Safety Data Sheet recommendations regarding chemical storage, use, and safety.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure signage identifying the location of alternative exits is posted during construction projects.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure signage is installed to clearly identify the location of fire extinguishers in large rooms and those obstructed from view.