Combined Assessment Program Review of the El Paso VA Health Care System, El Paso, Texas

Report Information

Issue Date
Report Number
13-03651-42
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
4
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 177 employees. This review focused on five operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) continuity of care, and (3) suicide prevention safety plans. The facility’s reported accomplishment was an audiology patient access systems redesign project. OIG made recommendations for improvement in the following two activities (1) quality management and (2) moderate sedation.

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 the Surgical Work Group meet monthly
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes a review of the history of any previous adverse experience with sedation 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 any changes to informed consents are discussed with and approved by the patients prior to administration of sedation and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patients who undergo moderate sedation are appropriately monitored during the procedure and that compliance be monitored.