Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut

Report Information

Issue Date
Report Number
13-01976-312
VISN
State
Connecticut
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 138 employees. This review focused on seven operational activities. The facility complied with selected standards in the construction safety activity. The facility’s reported accomplishments were the positive effect of the Systems Redesign Program for clinical and administrative operations, Compensation and Pension Program improvements, and contributions of the Center for Neuroscience and Regeneration/Neurorehabilitation Research. OIG made recommendations for improvement in the following six 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.

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 peer reviews are consistently completed and reported to the PRC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode and that the data collected from resuscitation episodes are critically analyzed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a quality control policy for scanning.
No. 4
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC Committee minutes include results of EOC rounds, identify who is responsible for correcting environmental deficiencies, and track deficiencies to closure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that restrooms and showers on inpatient units are clean.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that public restrooms and elevators are clean, that public restrooms are free from environmental safety hazards, and that automatic door opening switches in all public restrooms are operational.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate actions to address the four identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be implemented to ensure that quarterly trend reports are provided timely to the facility Director and that trending and analysis of the data includes all elements required by VHA policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required non-pharmacy and pharmacy areas with CS are inspected monthly.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that inspectors validate 2 transfers of CS from 1 storage area to another area and that 1 day’s dispensing from the pharmacy to each automated unit is consistently reconciled.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the PCCT includes a dedicated administrative support person and psychologist or other mental health provider.
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 the facility PU policy be revised to address prevention for outpatients and that compliance with the revised policy be monitored.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document PU location, stage, risk scale score, and date acquired.
No. 16
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 daily skin inspections for patients at risk for or with PUs and consistently revise prevention plans if the patients’ risk levels change.
No. 17
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 PU education for patients at risk for and with PUs and/or their caregivers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the PU risk scale, how to conduct a complete skin assessment, and how to accurately document findings.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that electrical medical equipment in PU patient rooms receives an electrical safety inspection.
No. 20
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.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nurse managers reassess the target nursing hours per patient day for the medical intensive care unit to more accurately plan for staffing and evaluate the actual staffing provided.