Report Summary

Title: Clinical Assessment Program Review of the Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
Report Number: 16-00553-135
Issue Date: 3/13/2017
City/State: Cleveland, OH
Akron, OH
Calcutta, OH
Canton, OH
Mansfield, OH
New Philadelphia, OH
Painesville, OH
Parma, OH
Ravenna, OH
Sandusky, OH
Sheffield Village, OH
Warren, OH
Youngstown, OH
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
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.