Combined Assessment Program Review of the Huntington VA Medical Center,Huntington, West Virginia

Report Information

Issue Date
Report Number
12-02602-79
VISN
State
West Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
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 109 employees. This review focused on nine activities. The facility complied with selected standards in the following four activities: (1) coordination of care, (2) medication management, (3) point-of-care testing, and (4) polytrauma. The facility’s reported accomplishments were the establishment of a Homeless Veterans Resource Center and recognition for a score of 10 out of 10 on their first external peer review. OIG made recommendations for improvement in the following five activities: (1) QM, (2) colorectal cancer screening (3) environment of care, (4) nurse staffing, and (5) moderate sedation.

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 PR analysis summary reports be discussed quarterly at the ECMS and that the discussion be documented in meeting minutes.
No. 2
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 ECMS.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a local policy mandating a Cardiopulmonary Resuscitation Committee.
No. 4
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. 5
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that smoking occurs in designated areas only.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff are able to locate MSDS for hazardous chemicals used in their areas.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that each unit has a unit-based expert panel and that each panel includes members from all nursing roles.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
No. 10
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.