Clinical Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa

Report Information

Issue Date
Report Number
16-00564-170
VISN
State
Iowa
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
18
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 Central Iowa 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; Management of Disruptive/Violent Behavior; and the Mental Health Residential Rehabilitation Treatment Program. OIG also provided crime awareness briefings to 11 employees, and an additional briefing is planned in April 2017. OIG identified certain system weaknesses in credentialing and privileging, utilization management, patient safety, general safety, environmental cleanliness, transfer documentation, point-of-care testing, history and physical examinations prior to moderate sedation, training for the management of disruptive and violent behavior, and Mental Health Residential Rehabilitation Treatment Program safety. As a result of the findings, OIG could not gain reasonable assurance that: (1) The process for reviewing Ongoing Professional Practice Evaluation data is effective; (2) Utilization management decisions are made with physician advisors’ input; (3) Root cause analysis feedback is provided to those who reported the incident; (4) The facility provides a safe and clean environment of care; (5) The facility safely transfers patients (6) Glucose point-of-care testing processes and procedures are effective; (6) Clinicians assess patients prior to moderate sedation; (8) The facility trains employees to manage disruptive/violent behavior; (9) The Mental Health Residential Rehabilitation Treatment Program environment is safe; and (10) The Marshalltown community based outpatient clinic had sustained improvements in the required reviews of its hazardous materials inventory. OIG made recommendations for improvement in the following seven review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Coordination of Care: Inter-Facility Transfers; (4) Diagnostic Care: Point-of-Care Testing; (5) Moderate Sedation; (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 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 provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Council meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure fire extinguisher locations are clearly identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure information technology network room visitor logs contain all the required elements and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees store expired medications separately from medications available for administration 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 ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure standard operating procedures for the bronchoscope are consistent with the manufacturer's instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers perform history and physical examinations within 30 calendar days prior to the moderate sedation procedure and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility correct the deficiencies identified for the Mental Health Residential Rehabilitation Treatment Program and that documentation reflects correction actions taken.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the review of the hazardous materials inventory at the Marshalltown CBOC occurs twice within a 12-month period.