Breadcrumb

Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa

Report Information

Issue Date
Report Number
13-03621-57
VISN
State
Iowa
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 37 employees. This review focused on seven operational activities. The facility complied with selected standards in the following four activities: (1) environment of care, (2) medication management, (3) coordination of care, and (4) community living center resident independence and dignity. The facility’s reported accomplishments were governance structure redesign and the “See Something Say Something” reporting campaign and tool. OIG made recommendations for improvement in the following three activities: (1) quality management, (2) nurse staffing, and (3) pressure ulcer prevention and management.

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 FPPE results for newly hired licensed independent practitioners are consistently reported to the MEC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Code Blue Committee reviews each code episode.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that nursing managers continue to complete annual staffing plan reassessments timely.
No. 4
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.