Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana

Report Information

Issue Date
Report Number
13-02316-322
VISN
State
Indiana
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 175 employees. This review focused on seven operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) quality management and (2) coordination of care – hospice and palliative care. The facility’s reported accomplishments were the implementation of the Geriatric Resources for Assessment and Care of Elders Program and the Mobile Prosthetic Van Program. OIG made recommendations for improvement in the following five activities and follow-up review area: (1) environment of care, (2) medication management – controlled substances inspections, (3) pressure ulcer prevention and management, (4) nurse staffing, (5) construction safety, and (6) follow-up on environment of care issue.

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 EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit 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 operating room employees who perform immediate use sterilization receive annual competency assessments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented 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 all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns 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 a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
No. 11
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 a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge 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 acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 13
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, daily risk scales, and daily monitoring for a change in condition for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 14
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 monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
No. 15
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 being discharged and that compliance be monitored.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish staff pressure ulcer education requirements and that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training 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 designated employees complete respirator fit testing and that compliance be monitored.