Combined Assessment Program Review of the VA Northern California Health Care System, Sacramento, California

Report Information

Issue Date
Report Number
12-03074-29
VISN
State
California
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 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 171 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) mental health treatment continuity, and (3) point-of-care testing. The facility’s reported accomplishments were a Systems Redesign Champion Award, events for homeless veterans, and the urology clinic redesign. OIG made recommendations for improvement in the following five activities: (1) QM, (2) environment of care, (3) coordination of care, (4) polytrauma, and (5) 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 processes be strengthened to ensure that results from FPPEs are consistently reported to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that IC Functional Committee meeting minutes include sufficient data analysis and planning for corrective actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all food items are labeled with expiration dates, that patient nutritional products are routinely inspected to ensure they are within their expiration dates, and that hand hygiene products are readily available.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that expired medications are removed and stored separately from medications available for administration.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that interdisciplinary treatment plans are developed for all polytrauma outpatients who require them.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with its polytrauma training requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology that was approved in September 2012.