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Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Black Hills Health Care System, Fort Meade, South Dakota

Report Information

Issue Date
Report Number
14-00909-191
VISN
State
Nebraska
South Dakota
Wyoming
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
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 Black Hills 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 McLaughlin, SD, and Scottsbluff, NE, CBOCs for site visits during the week of April 21, 2014, to evaluate the environments of care. OIG noted opportunities for improvement and made seven 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 signage is installed at the Scottsbluff CBOC to clearly identify the location of fire extinguishers.
No. 2
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 Scottsbluff CBOC.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that staff document the evaluation of patient¿s level of understanding for the medication education.