Breadcrumb

Combined Assessment Program Review of the VA Manila Outpatient Clinic, Manila, Philippines

Report Information

Issue Date
Report Number
13-00894-216
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
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. This review focused on 12 operational activities. The facility complied with selected standards in the following four activities (1) continuity of care, (2) emergency management, (3) women’s health, and (4) credentialing and privileging. The facility’s reported accomplishments were improved pharmacy processing, improved beneficiary travel claim processing, and improved access and coordination. OIG made recommendations for improvement in the following eight activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) suicide prevention, (5) vaccinations, (6) diabetic foot care, (7) management of test results, and (8) management of workplace violence.

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 facility initiate monitoring of the copy and paste function.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Peer Review Committee meets at least quarterly or that a notation be made if there are no cases to discuss for the quarter.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC and Infection Prevention/Control Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that infection prevention risk assessments are conducted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that fire extinguisher inspections are conducted monthly and documented.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a process be implemented to ensure that laboratory specimens are transported in a secure manner.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors verify hard copy prescriptions for 10 percent of the schedule II drugs dispensed in the outpatient pharmacy 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 patients at high risk for suicide and/or their families receive a copy of the safety plan.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians administer tetanus vaccinations when indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop and implement a policy related to screening and referral for at-risk diabetic patients.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that diabetic patients receive annual risk assessments with risk level scores and that the assessments are documented in the EHRs.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that diabetic patients at moderate or high risk receive foot exams at each routine primary care visit.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients are consistently notified of critical/abnormal test results and that notification is documented in the EHRs.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that debriefings occur after incidents of disruptive or violent behavior.