Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri

Report Information

Issue Date
Report Number
15-04695-231
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 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 130 employees. This review focused on seven operational activities. The facility’s reported accomplishment was initiation of a cochlear implant clinic. OIG made recommendations for improvement in all seven of the following activities: (1) quality, safety, and value; (2) environment of care; (3) medication management; (4) coordination of care; (5) computed tomography radiation monitoring; (6) advance directives; and (7) 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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility replace missing/stained ceiling tiles in patient care areas.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all patient care areas have secure storage for protected health information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility assess the possible subfloor penetration and replace missing and broken floor tiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees perform and document daily floor and monthly storage shelving cleaning in all compounding areas and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 9
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.