OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Clinical Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa
Report Number: 16-00564-170 Download
Report
Issue Date: 4/14/2017
City/State: Des Moines, IA
Carroll, IA
Fort Dodge, IA
Knoxville, IA
Marshalltown, IA
Mason City, IA
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 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...