Combined Assessment Program Review of VA Butler Healthcare, Butler, Pennsylvania

Report Information

Issue Date
Report Number
15-04706-104
VISN
State
Pennsylvania
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 (OIG) conducted a review to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 91 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) medication management – controlled substances inspection program, (2) continuity of care, and (3) management of workplace violence. The facility’s reported accomplishment was initiating acupuncture care. OIG made recommendations for improvement in the following five activities: (1) quality, safety, and value; (2) environment of care; (3) mammography services; (4) suicide prevention program; and (5) Mental Health Residential Rehabilitation Treatment Program.

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 facility clinical managers consistently review Ongoing Professional Practice Evaluation data semiannually and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that dental clinic managers ensure all dental clinic employees complete bloodborne pathogens training annually and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the Women Veterans Program Manager has sufficient allocated administrative time for oversight duties and does not provide direct patient care more than 1/8 of her time (5 hours per week).
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommend that clinicians develop and document Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that domiciliary managers ensure the Domiciliary Care for Homeless Veterans and Substance Abuse Domiciliary has written agreements in place acknowledging resident responsibility for medication security.