Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Western New York Healthcare System, Buffalo, New York

Report Information

Issue Date
Report Number
15-05155-89
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General conducted a review of the VA Western New York Healthcare System’s Community Based Outpatient Clinics (CBOCs) and other outpatient clinics to evaluate for safe, consistent, and high-quality health care. The review evaluated the clinics’ compliance with selected VHA requirements for home telehealth enrollment, outpatient lab results management, and post-traumatic stress disorder care. We also randomly selected the Buffalo VA Clinic, Buffalo, NY, as a representative site and evaluated the environment of care on November 3, 2015. OIG noted opportunities for improvement and made 13 recommendations in the following focused review areas: Home Telehealth Enrollment, Outpatient Lab Results Management, Post-Traumatic Stress Disorder Care, and Environment of Care.

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 managers monitor hand hygiene compliance at the Buffalo VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers document their consideration and implementation of safety needle devices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure fire drills are conducted at least every 12 months at the Buffalo VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers test the alarm system or panic buttons regularly at the Buffalo VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers maintain a clean environment of care at the Buffalo VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure hand hygiene products are readily accessible to employees at the Buffalo VA Clinic.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers provide feminine hygiene products in women’s public restrooms at the Buffalo VA Clinic.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers at the Buffalo VA Clinic ensure all medications are secured from unauthorized access.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers at the Buffalo VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers ensure that PTSD patients receive mental health treatment, when applicable.