Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Report Information

Issue Date
Report Number
16-00108-274
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
9
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. This review focused on seven operational activities and two follow-up review areas from the previous Combined Assessment Program review. The facility complied with selected standards in the following three activities: (1) coordination of care, (2) advance directives, and (3) environment of care. The facility’s reported accomplishment was an enhanced use lease to provide housing for homeless veterans. OIG made recommendations for improvement in the following six activities, which includes the follow-up review areas: (1) quality, safety, and value; (2) medication management; (3) computed tomography radiation monitoring; (4) suicide prevention program; (5) follow-up on quality management; and (6) follow-up on 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 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 annually assess the competency of pharmacy employees who prepare compounded sterile products 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 employees perform and document monthly cleaning of storage shelving in all compounding areas and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revisethe radiation safety policy to include a computed tomography quality control program with annual program monitoring by a medical physicist, image quality monitoring, and scanner maintenance; computed tomography protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer; a process for managing/reviewing computed tomography protocols and procedures to follow when revising protocols; and radiologist review of appropriateness of computed tomography orders.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managersconfirm computed tomography technologists have computed tomography certification prior to hiring them and ensure all current computed tomography technologists hired after July 1, 2014, have the certification.
No. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure Focused Professional Practice Evaluations for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure Sterile Processing Service employees responsible for reprocessing activities receive annual competency assessments.