Combined Assessment Program Review of the Cheyenne VA Medical Center, Cheyenne, Wyoming

Report Information

Issue Date
Report Number
16-00110-246
VISN
State
Wyoming
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
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 78 employees. This review focused on seven operational activities. The facility complied with selected standards in the medication management activity. The facility’s reported accomplishment was the telephone access initiative. OIG made recommendations for improvement in the following six activities: (1) quality, safety, and value; (2) environment of care; (3) coordination of care; (4) computed tomography radiation monitoring; (5) advance directives; and (6) 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 facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Physician Utilization Management Advisors document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure medical waste/biohazard containers are properly covered and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a policy that addresses temporary bed locations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the Radiation Safety Program policy to include a computed tomography quality control program with annual monitoring by a medical physicist and image quality monitoring, protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer, a process for managing/reviewing protocols and procedures to follow when revising protocols, and radiologist review of appropriateness of orders and specification of protocol prior to scans.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and tracking patients who are at high risk for suicide.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a process to follow up on high-risk patients who missed mental health appointments 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 ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.