Clinical Assessment Program Review of the VA Portland Health Care System, Portland, Oregon

Report Information

Issue Date
Report Number
16-00547-156
VISN
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
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 VA Portland Health Care System. 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; and Management of Disruptive/Violent Behavior. OIG also provided crime awareness briefings to 208 employees. OIG identified certain system weaknesses in utilization management; general safety and environmental cleanliness; anticoagulation processes; transfer documentation; moderate sedation policy, processes, and competency assessment; Community Nursing Home Oversight Committee representation and processes; management of disruptive/violent behavior training; and training of facility nursing expert panel members. As a result of this review, OIG could not gain reasonable assurance that: (1) the facility consistently performs all required utilization management reviews, (2) the facility completes all fire drills and ensures patient equipment is clean, (3) clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications, (4) clinicians document all required elements for the patient transfer process, (5) the facility documents required elements related to moderate sedation and ensures training is in place, (6) the facility provides oversight for the community nursing home program, and (7) the facility effectively trains employees to manage disruptive or violent behavior and ensures all members of the facility nursing expert panel receive the required training. 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) Moderate Sedation; (6) Community Nursing Home Oversight; and (7) Management of Disruptive/Violent Behavior. OIG made a repeat recommendation in Nurse Staffing related to nursing expert panel training.

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 ensure completion of at least 75 percent of all required inpatient utilization management reviews 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 all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure rolling equipment and exam table bases in patient care areas are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, providers consistently include date and time of transfer in transfer documentation and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers include all required elements in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical managers ensure clinical employees who perform or assist with moderate sedation procedures have current Talent Management System training for the provision of moderate sedation care, ensure the training is documented, and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy on correct surgery and invasive procedures to include all elements of the timeout checklist required by Veterans Health Administration Directive 1039.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Review Team completes timely annual reviews and monitor compliance.
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 all employees assigned to high-risk areas receive additional Prevention and Management of Disruptive Behavior training as required within 90 days of hire and that the training is documented in employee training records.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of the facility nursing expert panel receive the required training prior to the next annual staffing plan reassessment.