Combined Assessment Program Review of the Northern Arizona VA Health Care System, Prescott, Arizona

Report Information

Issue Date
Report Number
15-04704-297
VISN
State
Arizona
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
26
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 35 employees. This review focused on eight operational activities and three follow-up review areas from the previous Combined Assessment Program review. The facility’s reported accomplishment was receiving the VA National Center for Patient Safety’s Gold Cornerstone Award for fiscal year 2015. OIG made recommendations for improvement in the following 11 activities, which includes the follow-up review areas: (1) quality, safety, and value; (2) environment of care; (3) medication management; (4) coordination of care; (5) computed tomography radiation monitoring; (6) advance directives; (7) suicide prevention program; (8) mammography services; (9) follow-up on medication management – controlled substances inspection program; (10) follow-up on pressure ulcer prevention and management; and (11) follow-up on nurse staffing.

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 review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas and furnishings and equipment in patient care areas are clean and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers initiate actions to repair damaged furnishings and equipment in patient care areas or remove them from service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently monitor temperature in the inpatient pharmacy compounding buffer areas and that facility managers monitor compliance.
No. 5
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers develop a temporary bed location policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director appoint a Bed Flow Coordinator with a clinical background.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that physicians consistently document discharge progress notes or instructions that include all required elements and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a computed tomography policy and procedures that include all required components.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented annual radiation safety training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently correctly post patients’ advance directives status and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure new clinical employees complete suicide risk management training within the required timeframe and monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Suicide Prevention Coordinator provide at least five community outreach activities every month and maintain documentation of these activities and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently assess patients for suicide risk prior to placing a high risk for suicide flag and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians not place flags in the electronic health records of moderate- and low-risk patients and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians include the contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 19
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. 20
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.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers establish a mammography services policy.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians link mammogram results to the radiology order in the electronic health record and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure ordering clinicians receive signed written mammography reports within 30 days of the procedure date and monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Controlled Substances Coordinator provide the Facility Director with controlled substances inspection quarterly trend reports.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acute care employees provide pressure ulcer education to patients at risk for or with pressure ulcers and/or their caregivers and document the education and that facility managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology implemented in August 2013.