Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California

Report Information

Issue Date
Report Number
12-02189-14
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
15
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, OIG provided crime awareness briefings to 660 employees. This review focused on 12 activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) nurse staffing, and (3) QM. The facility’s reported accomplishment was the expedited placement confirmation of peripherally inserted central catheter lines. OIG made recommendations for improvement in the following nine activities: (1) moderate sedation, (2) point-of-care testing, (3) colorectal cancer screening, (4) polytrauma, (5) mental health treatment continuity, (6) coordination of care, (7) environment of care, (8) follow-up on coordination of care issue, and (9) follow-up on environment of care issues.

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 processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that outpatients who need interdisciplinary care have treatment plans developed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that discharge instructions address diet and the initial follow-up appointment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and documented.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be implemented to report results of tracking and trending of inter-facility transfers to the Organizational Excellence Board and to incorporate education on inter-facility transfers into new resident orientation.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC deficiencies are corrected within the required timeframe and that action plans are submitted for deficiencies not corrected within the required timeframe.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers conduct a comprehensive EOC inspection of the facility and take appropriate actions to correct identified general cleanliness and maintenance issues.