Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama

Report Information

Issue Date
Report Number
13-01673-240
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
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 106 employees. This review focused on six operational activities. The facility complied with selected standards in the following two activities (1) medication management – controlled substances inspections and (2) nurse staffing. The facility’s reported accomplishments were the geriatric suicide screening tool and the Green House® Project. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) coordination of care – hospice and palliative care, and (4) 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 FPPEs for newly hired licensed independent practitioners are reported timely to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inpatient bathrooms are clean and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes on the acute MH inpatient units be strengthened to ensure that nurses' stations and medication rooms are secured from unauthorized entry and that furniture meets safety requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities receive annual competency assessments.
No. 6
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 administrative support person.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the multidisciplinary committee responsible for construction and renovation oversight includes all required members.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that construction site inspection documentation includes all the required elements.