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Combined Assessment Program Review of the Carl Vinson VA Medical Center, Dublin, Georgia

Report Information

Issue Date
Report Number
16-00115-263
VISN
State
Georgia
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 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 849 employees. This review focused on eight operational activities. The facility complied with selected standards in the following two activities (1) medication management and (2) computed tomography radiation monitoring. The facility’s reported accomplishments were its waste management program, pharmacist led congestive heart failure clinics, and volunteer services. OIG made recommendations for improvement in the following six activities: (1) quality, safety, and value; (2) environment of care; (3) coordination of care; (4) advance directives; (5) suicide prevention program; and (6) 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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure Peer Review Committee monthly meetings are documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee meeting minutes reflect sufficient discussion of environment of care rounds deficiencies, corrective actions taken to address the deficiencies, and tracking of actions to closure for the facility and the community based outpatient clinics.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure operating room housekeepers complete initial training on cleaning and disinfection procedures.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop a policy that addresses temporary bed locations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently identify and document deficiencies concerning resident privacy, submit work orders for items needing repair, and document corrective actions taken for identified deficiencies and that program managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband, 2-hour rounds of all public spaces, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the unit 10-B and unit 8-B main points of entry have keyless entry systems.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that the closed circuit television system on unit 8-B have recording capabilities and that unit 10-B have signage alerting veterans and visitors of closed circuit television recording.