Combined Assessment Program Review of the White River Junction VA Medical Center, White River Junction, Vermont

Report Information

Issue Date
Report Number
13-04240-60
VISN
State
Vermont
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected health care operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 112 employees. This review focused on six operational activities. The facility complied with selected standards in the following two activities (1) environment of care and (2) coordination of care. The facility’s reported accomplishments were the No Veteran Dies Alone program for hospice patients and the tele-scheduling process for the Sensory/Physical Rehabilitation Service. OIG made recommendations for improvement in the following four activities: (1) quality management (2) medication management, (3) nurse staffing, and (4) 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 actions from peer reviews are consistently completed and reported to the PRC.
No. 2
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 CEB.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the local observation bed policy be revised to include how the responsible service and provider are determined and that each observation patient must have a focused goal for the period of observation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Operative and Invasive Procedure Committee meet monthly and include the Chief of Staff as a member.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Blood Usage Review Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that nursing managers complete annual staffing plan reassessments timely.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 9
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 daily and at discharge and develop interprofessional treatment plans 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 acute care staff accurately document pressure ulcer stages, risk scale scores, and wound improvement or deterioration, including wound characteristics, from the time of admission to the time of discharge.
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 provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.