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Clinical Assessment Program Review of the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio

Report Information

Issue Date
Report Number
16-00553-135
VISN
State
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the Louis Stokes Cleveland VA Medical Center. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; Management of Disruptive/Violent Behavior; and Mental Health Residential Rehabilitation Treatment Program. OIG also provided crime awareness briefings to 128 employees. OIG identified certain system weaknesses in credentialing and privileging, utilization management, patient safety, environmental cleanliness, anticoagulation practices, transfer processes, community nursing home oversight committee activities and clinical visits, training related to the management of disruptive and violent behavior, and Mental Health Residential Rehabilitation Treatment Program processes. As a result of the findings, OIG could not gain reasonable assurance that: (1) clinical managers effectively monitor the professional competency of providers, physician advisors’ input is considered when making utilization management decisions, and patient safety incidents are effectively communicated to facility and Veterans Health Administration leadership; (2) patient equipment is clean; (3) clinicians effectively monitor patients receiving anticoagulation or safely transfer patients from the facility; (4) facility leaders monitor the community nursing home program and assure the safe care of patients in those homes; (5) employees are trained to reduce and prevent disruptive behaviors; and (6) facility employees ensure a safe and healthy environment in the Mental Health Residential Rehabilitation Treatment Program. OIG made recommendations for improvement in the following seven review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Community Nursing Home Oversight; (6) Management of Disruptive/Violent Behavior; and (7) 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 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 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 facility managers ensure that wheelchairs are free of tape and clean and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure clinicians obtain all required laboratory tests prior to initiating warfarin.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility prior to or within a few hours after the transfer and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure transfer notes written by acceptable designees contain attending physician countersignature and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Oversight Committee meets at least quarterly and includes representation by all required clinical disciplines.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that employees complete annual onsite inspections as required by local policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that domiciliary employees perform and document contraband inspections, rounds of all public spaces, and resident room inspections for unsecured medications and that domiciliary managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that domiciliary employees perform and document hourly safety and security rounds and that domiciliary managers monitor compliance.