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Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut

Report Information

Issue Date
Report Number
16-00116-323
VISN
State
Connecticut
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
9
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 275 employees. This review focused on seven operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) coordination of care and (2) computed tomography radiation monitoring. The facility’s reported accomplishments were the Outstanding Achievement Award from the American College of Surgeons Commission on Cancer and the Homeless Team’s successes. OIG made recommendations for improvement in the following six activities, which includes the follow-up review area: (1) quality, safety, and value; (2) environment of care; (3) medication management; (4) advance directives; (5) suicide prevention program; and (6) follow-up on nurse staffing.

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 every 6 months and that facility managers monitor compliance.
No. 2
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees follow facility policy for disinfecting exam tables after each patient use and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure annual competency assessment for pharmacy employees who prepare compounded sterile products includes a written test and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Suicide Prevention Coordinators consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nurse managers accurately monitor the nurse staffing methodology implemented in March 2013 and use the standard nursing hours per patient day calculation to assess nurse staffing adequacy for all units.