Combined Assessment Program Review of the Sheridan VA Healthcare System, Sheridan, Wyoming

Report Information

Issue Date
Report Number
13-01671-262
VISN
State
Wyoming
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
24
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 175 employees. This review focused on six operational activities. The facility’s reported accomplishment was the achievement of an employee flu vaccination rate of 76 percent compared to the national average of 48 percent. OIG made recommendations for improvement in all six of the following activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, (5) pressure ulcer prevention and management, and (6) nurse staffing.

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that ECC membership includes all required disciplines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
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 care are consistently scanned into EHRs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that results of compliance with RME SOPs are reported to the RME Management Committee and the MEB.
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 initial RME training and 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 manufacturers’ instructions are available for all RME items, that RME is reprocessed at the specified temperature, and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SPS sterile storage area temperature and humidity levels are consistently monitored and maintained within acceptable levels.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility policy be amended to include the requirement that CS inspectors receive annual updates regarding problematic issues identified through external survey findings and other quality control measures and that processes be strengthened to ensure that CS inspectors receive annual updates.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop instructions for inspections of automated dispensing machines and that processes be strengthened to ensure that monthly findings summaries are provided to the facility Director and that quarterly trend reports clearly summarize discrepancies and problematic trends and identify potential areas for improvement.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors’ appointments state the end date of their term and that CS inspectors’ terms do not exceed 3 years.
No. 11
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 are conducted in accordance with VHA requirements and include all required elements and that compliance be monitored.
No. 12
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that HPC inpatients’ pain is consistently assessed whenever vital signs are obtained and results documented in EHRs and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that HPC inpatients’ pain assessments are documented in EHRs using approved note titles and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the interprofessional pressure ulcer committee includes a certified wound care specialist.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer location and stage and perform and document all required daily activities/inspections for patients with pressure ulcers and that compliance be monitored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document recommended pressure ulcer interventions and that compliance be monitored.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff perform and document skin inspections and risk scales at discharge and that compliance be monitored.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to discharge and that compliance be monitored.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients and/or their caregivers and that compliance be monitored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology that was implemented in March 2013.