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Community Based Outpatient Clinic and Primary Care Clinic Reviews at Harry S. Truman Memorial Veterans' Hospital, Columbia, Missouri

Report Information

Issue Date
Report Number
13-03424-74
VISN
State
Missouri
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 VA Office of Inspector General reviewed the Community Based Outpatient Clinics (CBOCs) and primary care clinics (PCCs) of the Harry S. Truman Memorial Veterans’ Hospital. 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 Waynesville (Fort Leonard Wood), Osage Beach (Lake of the Ozarks), and Mexico, MO, CBOCs for site visits during the week of December 9, 2013, to evaluate the environment of care. OIG noted opportunities for improvement and made 13 recommendations in the following reviews: Environment of Care, Alcohol Use Disorder, Medication Management, and Designated Women’s Health Providers’ Proficiencies.

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 are improved to ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that panic alarm testing is documented at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire drills are performed every 12 months at the Fort Leonard Wood and Lake of the Ozarks CBOCs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Lake of the Ozarks and Mexico CBOCs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Mexico CBOC.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility include staff at the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs in required education, training, planning, and participation in annual disaster exercises.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility document EMP-specific training completed for the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs clinical providers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the parent facility's EMC evaluate the Fort Leonard Wood, Lake of the Ozarks, and Mexico CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff consistently complete follow-up assessments for patients with a positive alcohol screen.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that RN Care Managers receive MI and health coaching training within 12 months of appointment to PACT.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical executive/primary care leaders ensure that CBOC/PCC DWHPs maintain proficiency as required for the provision of women's health care.