Breadcrumb

Combined Assessment Program Review of the VA Southern Nevada Healthcare System, Las Vegas, Nevada

Report Information

Issue Date
Report Number
13-00888-203
VISN
State
Nevada
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 health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 230 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) environment of care and (2) long-term home oxygen therapy. The facility’s reported accomplishments were the new facility and clinic activation, the secure messaging program, and patient-centered care initiatives at the new facility. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, (4) nurse staffing, and (5) preventable pulmonary embolism.

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 actions from PRs are consistently completed and reported to the PR Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility monitor compliance with the recently implemented observation bed use policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate actions to address identified deficiencies in the PCC pharmacies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop instructions for inspecting automated dispensing machines that include all VHA requirements and that compliance be monitored.
No. 6
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 and/or refresher training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CS Coordinator only performs occasional inspections and that a sufficient number of CS inspectors are appointed to conduct the monthly inspections.
No. 8
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility fully implement the nurse staffing methodology.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate protected PR for the one identified patient and complete any recommended review actions.