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Combined Assessment Program Review of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas

Report Information

Issue Date
Report Number
15-04696-107
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
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 180 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) continuity of care, and (3) computed tomography radiation monitoring. OIG made recommendations for improvement in the following four activities: (1) quality, safety, and value; (2) medication management – controlled substances inspection program; (3) mammography services; and (4) 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 Patient Safety Manager ensure completion of eight root cause analyses each fiscal year and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently reconcile 1 day's dispensing from the pharmacy to each automated unit and that the Controlled Substances Coordinator monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the Controlled Substances Coordinator's position description includes controlled substances oversight duties.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure controlled substances inspectors receive annual updates and refresher training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Controlled Substances Coordinator ensure random scheduling of non-pharmacy area inspections with no distinguishable patterns and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently validate transfers from one storage area to another and that the Controlled Substances Coordinator monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently verify hard copy orders for five randomly selected dispensing activities (or a minimum of two if less than five dispensing activities on the unit) and that the Controlled Substances Coordinator monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that pharmacy employees consistently perform 72-hour inventories of the main vault and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently compare drugs held for destruction with the Destruction File Holding Report for 10 randomly selected drugs and that the Controlled Substances Coordinator monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that controlled substances inspectors consistently verify completion of drug destructions at least quarterly and that the Controlled Substances Coordinator monitors compliance.
No. 11
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. 12
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians include the contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.