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Clinical Assessment Program Review of the Lebanon VA Medical Center, Lebanon, Pennsylvania

Report Information

Issue Date
Report Number
16-00571-207
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care provided at the Lebanon 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; Community Nursing Home Oversight; Management of Disruptive/Violent Behavior; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG provided crime awareness briefings to 149 employees. OIG identified certain system weaknesses in credentialing and privileging, utilization management, peer review, patient safety, information technology network security, anticoagulation processes, Community Nursing Home Oversight Committee representation and clinical visits, management of disruptive and violent behavior training, Mental Health Residential Rehabilitation Treatment Program environmental safety, and care provided for patients with positive post-traumatic stress disorder screens. As a result of the findings, OIG could not gain reasonable assurance that: (1) The quality, safety, and value program has effective processes; (2) The facility monitors access to the information technology network; (3) The facility minimizes the risk of anticoagulation dosing errors; (4) Clinicians obtain all required laboratory tests prior to initiating anticoagulant medications; (5) The facility provides multidisciplinary oversight of the community nursing home program; (6) The facility trains employees to manage disruptive/violent behavior; (7) The facility maintains a safe Mental Health Residential Rehabilitation Treatment Program environment; (8) Clinicians provide suicide risk assessments and offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screening results. OIG made recommendations for improvement in seven review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Community Nursing Home Oversight; (5) Management of Disruptive/Violent Behavior; (6) Mental Health Residential Rehabilitation Treatment Program; and (7) Post-Traumatic Stress Disorder Care.

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 twice a year and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure peer reviewers consistently document their use of at least one of the important aspects of care and that facility managers monitor compliance.
No. 3
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. 4
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. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
No. 7
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. 8
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. 9
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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive 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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Residential Recovery Center employees perform and document contraband inspections and rounds of public spaces and that managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.