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Community Based Outpatient Clinic Reviews Franklin, WV; Stephens City, VA; Greenbelt, MD; Southeast Washington, DC

Report Information

Issue Date
Report Number
12-00580-50
VISN
State
District of Columbia
Maryland
Virginia
West Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
20
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed four Community Based Outpatient Clinics (CBOCs) during the week of July 9, 2012. CBOCs were reviewed in Veterans Integrated Service Network (VISN) 5 at Franklin, WV; Stephens City, VA; Greenbelt, MD; and Southeast Washington, DC. The purpose of the review was to assess whether CBOCs are operated in a manner that provides veterans with consistent, safe, high-quality health care. The review covered the following focused topic areas: women’s health, management of diabetes mellitus-lower limb peripheral vascular disease, heart failure follow-up, credentialing and privileging, environment and emergency management, and CBOC contracts. OIG noted opportunities for improvement and made a total of 20 recommendations to the VISN and facility managers.

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 the Franklin and Stephens City CBOC clinicians document education of foot care to diabetic patients in CPRS.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Franklin and Stephens City CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Southeast Washington CBOC clinicians document complete foot screenings for diabetic patients in CPRS.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Greenbelt and Southeast Washington CBOC clinicians document education of foot care to diabetic patients in CPRS.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Greenbelt and Southeast Washington CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Stephens City CBOC establish a process to ensure that patients with normal mammograms are notified of results within the allotted timeframe and that notification is documented in the medical record.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the managers at the Greenbelt and Southeast Washington CBOCs ensure that all mammogram results are documented using the BI-RADS code categories.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Women's Health Program Manager at the Washington DC VAMC ensure that the Greenbelt and Southeast Washington CBOC fee-basis mammography results are received and scanned into CPRS.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Executive Committee of the Medical Staff, Credentialing Committee, grant privileges consistent with the services provided at the Franklin and Stephens City CBOCs.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the process is strengthened to ensure that privileges granted to psychologists are provider specific and consistent with the setting in which the services are provided at the Greenbelt CBOC.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that privacy is maintained at all times during a patient physical examination at the Franklin CBOC.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the Franklin CBOC to clearly identify the location of fire extinguishers.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire extinguishers are inspected at the Franklin CBOC and that maintenance and inspection dates are documented in accordance with NFPA Life Safety Code.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that biohazardous waste containers are stored appropriately and that clean and dirty items are stored in separate locations at the Franklin CBOC.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the electrical closet is free of hazardous chemicals at the Stephens City CBOC.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire drills and fire safety inspections are conducted annually at the Greenbelt CBOC.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director determines, with the assistance of the Regional Counsel, the extent and collectability of the overpayments at the Franklin CBOC.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensures that the contractor provide the invoice in the prescribed format at the Franklin CBOC.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensures that all the performance-reporting provisions of the contract are completed and monitored at the Franklin CBOC.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director considers adding controls in the invoice validation process, such as preparing a monthly billable roster with VA data at the Franklin CBOC.