Clinical Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania

Report Information

Issue Date
Report Number
16-00555-337
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
12
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 James E. Van Zandt VA Medical Center. 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; Community Nursing Home (CNH) Oversight; Management of Disruptive/Violent Behavior; and Post-Traumatic Stress Disorder Care. OIG provided crime awareness briefings to 50 employees. OIG identified certain system weaknesses in taking actions for issues identified by quality, safety, and value reviews; medical staff membership; general safety and security of personally identifiable information at the Huntingdon County VA Clinic; the anticoagulation management program; inter-facility transfer data collection and reporting; point-of-care testing follow-up; CNH oversight and clinical visits; and disruptive behavior training. As a result of the findings, OIG could not gain reasonable assurance that: (1) The facility takes actions for weaknesses identified in peer review and Focused Professional Practice Evaluations. (2) Facility leadership is able to perform appropriate oversight of all medical staff members. (3) The access log for the Huntingdon County VA Clinic information technology network room contains required elements. (4) The Huntingdon County VA Clinic secures patients’ personally identifiable information. (5) A physician is involved in the anticoagulation management program. (6) Data is used to improve inter-facility transfers. (7) Clinicians document required actions in response to glucose point-of-care testing results. (8) The facility effectively oversees the CNH program and monitors and assures the safe care of patients in the program. (9) Facility employees are trained to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following seven areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Diagnostic Care; (6) CNH Oversight; and (7) Management of Disruptive/Violent Behavior.

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 the facility consistently take action when data analyses indicated problems or opportunities for improvement and evaluate the actions for effectiveness in peer review and Focused Professional Practice Evaluations and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Chief of Staff ensure that all required practitioners are designated as members of the medical staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the access log for the Huntingdon County VA Clinic information technology network room includes all required elements to document access and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Huntingdon County VA Clinic and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility designate a physician anticoagulation program champion.
No. 6
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. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
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 integration of the community nursing home program into its quality improvement program.
No. 10
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a VA physician order or approve all therapies that are at VA expense.
No. 12
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 training is documented in employee training records.