Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma

Report Information

Issue Date
Report Number
16-00011-259
VISN
State
Oklahoma
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 of the Eastern Oklahoma 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 Hartshorne VA Clinic, Hartshorne, OK, as a representative site and evaluated the environment of care on January 25, 2016. OIG noted opportunities for improvement and made 14 recommendations in the following focused review areas: 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 employees at the Hartshorne VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that Hartshorne VA Clinic staff participate in emergency management training and exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensures that a policy/procedure is in place for the identification of individuals entering the Hartshorne VA Clinic.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensures that a Workplace Behavioral Risk Assessment is in place for the Hartshorne VA Clinic.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensures examination room doors are equipped with electronic or manual locks at the Hartshorne VA Clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Hartshorne VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Hartshorne VA Clinic manager provides feminine hygiene disposal bins in women's public restrooms.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Hartshorne VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
No. 9
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. 10
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
No. 12
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. 13
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.