Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts

Report Information

Issue Date
Report Number
12-04604-127
VISN
State
Massachusetts
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
21
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was 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 47 employees. This review focused on seven activities. The facility’s reported accomplishment was a pharmacy initiative to enhance medication safety and patient compliance, which also resulted in inventory reduction and cost savings. OIG made recommendations for improvement in all seven activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) long-term home oxygen therapy, (6) nurse staffing, and (7) construction safety.

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 the Medical Emergency Committee collects data that measures performance in responding to resuscitation events and that code reviews include screening for clinical issues prior to codes that may have contributed to the occurrence of the codes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning includes the linking of scanned documents to the correct EHR and that processes be strengthened to ensure that the review of EHR quality includes all services and that EHR quality review reports are analyzed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that actions taken when data analyses indicate problems or opportunities for improvement are evaluated for effectiveness in Geriatric and Extended Care Performance Improvement Council data and the Patient Flow Coordination Collaborative.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers correct the identified cleanliness and environmental safety issues and that the EOC Committee documents progress in EOC Committee minutes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that multi-dose medication vials are dated when opened and discarded when expired.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate actions to address the identified physical security deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that 1 day's dispensing from the pharmacy to each automated unit is reconciled and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that quarterly trend reports are provided to the facility Director.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the CS Coordinator's duties be included in his or her position description.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all CS inspectors are appointed in writing by the facility Director prior to assuming their duties.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors receive annual updates.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that monthly inspections of all pharmacy and non-pharmacy areas with CS include all required elements and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the PCCT includes a dedicated physician and administrative support person.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that HPC consult responses are attached to the consult request in the Computerized Patient Record System.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients are re-evaluated for home oxygen therapy annually after the first year.
No. 17
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 members of the unit-based and facility expert panels.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility complete the staffing methodology process.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a construction safety program with a multidisciplinary committee that effectively monitors infection control, safety, and security issues during construction and renovation activities in accordance with VHA requirements.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all identified infection control, safety, and security deficiencies for the Building 7 construction project be corrected and that compliance be monitored. VA