Report Summary

Title: Clinical Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
Report Number: 16-00568-292
Issue Date: 7/13/2017
City/State: Iron Mountain, MI
Hancock, MI
Ironwood, MI
Marquette, MI
Menominee, MI
Sault Saint Marie, MI
Sault Saint Marie, MI
Rhinelander, WI
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 in the inpatient and outpatient settings of the Oscar G. Johnson 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; and Management of Disruptive/Violent Behavior. OIG also followed up on recommendations from the previous Combined Assessment Program and Community Based Outpatient Clinic and Primary Care Clinic reviews and provided crime awareness briefings to 325 employees. OIG identified certain system weaknesses in patient privacy, transfer documentation, point-of-care testing, community nursing home oversight and clinical visits, and management of disruptive/violent behavior employee training. As a result of the findings, OIG could not gain reasonable assurance that: (1) Patients’ personally identifiable information is secured on laboratory specimens at the Menominee community based outpatient clinic; (2)Staff/attending physicians approve all patient transfers initiated by acceptable designees; (3) Clinicians take and document all required actions in response to glucose point-of-care testing results; (4) The facility effectively oversees the community nursing home program, consistently performs required cyclical reviews of patient care provided through the community nursing home program, and approves therapies provided at VA expense; (5) All facility employees are trained to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following five review areas: (1) `Environment of Care; (2) Coordination of Care: Inter-Facility Transfers; (3) Diagnostic Care: Point-of-Care Testing; (4) Community Nursing Home Oversight; and (5) Management of Disruptive/Violent Behavior.