Clinical Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky

Report Information

Issue Date
Report Number
16-00580-303
VISN
State
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
24
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 Lexington VA Medical Center. This included 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 Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP). OIG provided crime awareness briefings to 295 employees. OIG identified certain system weaknesses in utilization management; general safety and security; cleanliness; reusable medical equipment reprocessing and competencies; bloodborne pathogens training; anticoagulation policy, procedures, and competencies; transfer documentation; moderate sedation practices and training; community nursing home program oversight; disruptive/violent behavior management and training; MH RRTP privacy; and MH unit panic alarm testing. As a result of the findings, OIG could not gain reasonable assurance that: (1) Physician advisors document utilization management decisions; (2) The facility has effective reusable medical equipment reprocessing processes and a clean and safe reprocessing environment; (3) The Cooper Division maintains clean ventilation grills and monitors after-hours visitors; (4) Hemodialysis unit employees receive bloodborne pathogens training; (5) Anticoagulation policies include requirements, employees review quality assurance data, and competency assessments include all elements; (6) Transfer notes contain required elements; (7) Moderate sedation clinicians safely discharge outpatients and have current training; (8) Facility leaders monitor the community nursing home program; (9) Disruptive/violent behavior is managed, and employees receive training; (10) The facility maintains MH RRTP privacy and has a safe MH unit environment. OIG made recommendations in the following eight areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Moderate Sedation; (6) Community Nursing Home Oversight; (7) Management of Disruptive/Violent Behavior; and (8) MH RRTP. OIG made a repeat recommendation for panic alarm testing.

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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Infection Control Committee document analysis of surveillance data related to follow-up activities for the hemodialysis unit and Sterile Processing Service areas.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers at the Cooper Division implement the use of a visitors log during non-business hours and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers at the Cooper Division ensure ceiling ventilation grills in patient care areas are clean and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Sterile Processing Service managers ensure quality control testing is performed on endoscopes that exceed a 12-day hang time and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training and competencies for the types of reusable medical equipment they reprocess.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure wall and ceiling holes and damage are repaired.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees entering Sterile Processing Service areas wear the required personal protective equipment and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure current standard operating procedures for reusable medical equipment are located in the area where reprocessing occurs.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the distance of items stored below a sprinkler deflector complies with Joint Commission standards and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all hemodialysis unit employees receive annual bloodborne pathogens training and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the anticoagulation management policy to include required baseline laboratory tests.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility review quality assurance data for the anticoagulation management program biannually and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers include nutrient interactions and drug to drug interactions associated with anticoagulation therapy in competency assessments for employees actively involved in the anticoagulant program and monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical employees discharge outpatients from the recovery area according to provider orders or criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical managers ensure that clinical employees who perform or assist with moderate sedation have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 18
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 disciplines.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal flag placement and monitor compliance.
No. 22
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, ensure the training is documented in employee training records, and monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program monthly self-inspections include assessment of privacy and that facility managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure locked mental health unit panic alarm testing includes VA Police response time and monitor compliance.