Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Northern Arizona VA Health Care System, Prescott, Arizona

Report Information

Issue Date
Report Number
15-05160-161
VISN
State
Arizona
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 of the Northern Arizona VA Health Care 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 Chinle VA Clinic, Chinle, AZ, as a representative site and evaluated the environment of care on November 18, 2015. OIG noted opportunities for improvement and made 18 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 Chinle VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the managers develop and implement a policy/procedure for the life safety elements at the Chinle VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers develop and implement a policy that requires the Chinle VA Clinic staff to receive regular information on their responsibilities in emergency response operations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that Chinle VA Clinic staff participate in emergency management exercises.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure walls in patient care areas at the Chinle VA Clinic are repaired.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that the Chinle VA Clinic has functional and accessible hand hygiene facilities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers at the Chinle VA Clinic ensure food and drink are not kept in refrigerators or freezers in patient care areas.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers control access to and from areas identified as security sensitive at the Chinle VA Clinic.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers review the Chinle VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers equip examination room doors with electronic or manual locks at the Chinle VA Clinic.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers provide feminine hygiene products and disposal bins in women’s public restrooms at the Chinle VA Clinic.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers at the Chinle VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 14
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. 15
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 policy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.