Combined Assessment Program Review of the Philadelphia VA Medical Center, Philadelphia, Pennsylvania

Report Information

Issue Date
Report Number
13-01974-337
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
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 100 employees. This review focused on six 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) pressure ulcer prevention and management and (2) nurse staffing. The facility’s reported accomplishment was an improved orthopedic surgery joint replacement patient flow process, which allows patients to stay on the same unit for post-surgical care and rehabilitation. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, and (5) follow-up on environment of care issues.

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 consistently initiated and that results are reported to the PSB.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire extinguisher signage be in place and operational in accordance with National Fire Protection Association Standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated hemodialysis employees receive annual bloodborne pathogens training.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that chemicals stored on the hemodialysis unit be secured at all times 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 OR employees who perform IUS receive annual competency assessments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure monthly inspections are completed in the inpatient pharmacy, the outpatient pharmacy, and the CLC vault and for the emergency drug cache 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 the PCCT includes a dedicated administrative support person and a psychologist.
No. 11
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the identified environmental hazards on the locked MH unit be corrected and that processes be strengthened to ensure that all environmental hazards on the locked MH units are identified and corrected.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all staff who work on locked inpatient MH units and MSIT members receive annual environmental hazards training.