Clinical Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana

Report Information

Issue Date
Report Number
16-00577-335
VISN
State
Indiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
19
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the VA Northern Indiana Health Care System. This included reviews 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 provided crime awareness briefings to 53 employees. OIG identified certain system weaknesses in utilization management; environmental cleanliness; anticoagulation processes and competency assessment; transfer data collection and documentation; re-evaluations prior to moderate sedation procedures; community nursing home clinical visits; disruptive behavior program implementation, processes, and training; and credentialing and privileging. As a result of the findings, OIG could not gain reasonable assurance that: (1) Physician advisors provide input for utilization management decisions. (2) The facility maintains clean bed frames. (3) The facility has a comprehensive anticoagulation therapy management program. (4) The facility has effective processes for the safe transfer of patients. (5) Clinicians re-evaluate patients prior to moderate sedation procedures. (6) The facility monitors and assures the safe care of patients in the community nursing home program by conducting clinical visits. (7) The facility effectively manages disruptive/violent behavior incidents, and employees receive training to reduce and prevent disruptive behaviors. (8) The facility has an effective process for approving another facility’s physicians for teledermatology services and obtaining professional practice evaluation data for telemedicine providers. OIG made recommendations for improvement in the following seven review 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; and (7) Management of Disruptive/Violent Behavior. OIG made repeat recommendations from the previous Combined Assessment Program review in Quality Management.

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 facility managers ensure clean bed frames in patient care areas and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility designate a physician anticoagulation program champion.
No. 5
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
No. 7
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 12
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 for community nursing home oversight and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility’s Disruptive Behavior Committee include a senior clinician chair and the Patient Safety Manager and/or Risk Manager and that the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
No. 16
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 Patient Record Flag placement.
No. 17
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. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that that the Medical Executive Committee discuss and document its approval of the use of another facility’s physicians for teledermatology services.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.