Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Montana Health Care System, Fort Harrison, Montana

Report Information

Issue Date
Report Number
13-03416-56
VISN
State
Montana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
17
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General reviewed the Community Based Outpatient Clinics (CBOCs) and primary care clinics (PCCs) of the VA Montana Health Care System. The purpose of the review was to determine whether the CBOCs and PCCs provide safe, consistent, and high-quality health care for our veterans. The review covered the clinical care components of alcohol use disorder and medication management and evaluated if processes were in place for designated women’s health providers to maintain proficiency in women’s health. We also randomly selected the Cut Bank, MT, and Miles City, MT, CBOCs for site visits during the week of November 4, 2013, to evaluate the environments of care. OIG noted opportunities for improvement and made 17 recommendations in the following reviews: Alcohol Use Disorder, Medication Management, and Environment of Care.

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 side entrance door is ADA accessible at the Cut Bank CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the restroom is ADA accessible at the Cut Bank CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period for the Cut Bank and Miles City CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the Cut Bank CBOC to clearly identify the location of fire extinguishers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that signage is installed at the Cut Bank CBOC to clearly identify exits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the IT server closets at the Cut Bank and Miles City CBOCs are maintained according to IT safety and security standards.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that computer screens are secured to eliminate viewing of PII by unauthorized individuals at the Miles City CBOC.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that an AED is available at the Miles City CBOC.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility document EMP-specific training completed for the Cut Bank and Miles City CBOCs' clinical providers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility¿s EMC evaluate the Cut Bank and Miles City CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently complete follow-up assessments for patients with a positive alcohol screen.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff provide education and counseling for patients with positive alcohol screen and drinking levels above NIAAA limits.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC RN Care Managers receive MI training within 12 months of appointment to PACT.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff document medication reconciliation that includes the newly prescribed fluoroquinolones in the EHR.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff provide and document medication counseling/education that includes the fluoroquinolone.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/PCC staff document the evaluation of patient's level of understanding for the medication education.