Breadcrumb

Healthcare Inspection – Quality of Care Concerns at a Residential Rehabilitation Treatment Program, VA Maryland HCS, Baltimore, MD

Report Information

Issue Date
Report Number
14-01910-459
VISN
State
Maryland
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to complaints regarding documentation and follow-up of clinical events at the Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP) located at Perry Point VA Medical Center, Maryland VA Healthcare System, Baltimore, MD. We did not substantiate the allegation that facility staff did not follow sufficient practices to manage significant clinical events. We substantiated the allegation that some staff did not consistently document significant clinical events in patients’ electronic health records. We did not substantiate the allegation that subject policy-makers knew of documentation lapses but took no action to correct them. Prior to our inspection, and for unrelated reasons, the current MH Clinical Center Director identified concerns and took steps to revise and improve MH RRTP documentation processes. We found that the MH RRTP medical provider staffing of 1.2 providers was not compliant with the Veterans Health Administration’s required minimum core staffing guidelines of 2.3 providers and that staff did not consistently comply with all safe medication management documentation elements. On September 24, 2014, the Chief of Staff approved the hiring of one additional physician and two mid-level practitioners to cover MH programs. We recommended that the System Director ensure that MH RRTP medical providers document information pertinent to medical decision-making related to clinical events in the electronic health record, managers review and address medical provider staffing needs, and staff document in the electronic health record all required elements of safe medication management for MH RRTP patients.

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 System Director ensure that Mental Health Residential Rehabilitation Treatment Program medical providers document pertinent information related to medical decision-making in the electronic health record and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program managers review and address medical provider staffing needs in the Mental Health Residential Rehabilitation Treatment Program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Mental Health Residential Rehabilitation Treatment Program staff complete all required elements of the safe medication management program.