Report Summary

Title: Clinical Assessment Program Review of the VA Eastern Colorado Health Care System, Denver, Colorado
Report Number: 16-00546-388 Download
Issue Date: 9/29/2017
City/State: Denver, CO
Aurora, CO
Golden, CO
Pueblo, CO
Alamosa, CO
Colorado Springs, CO
La Junta, CO
Lamar, CO
Burlington, CO
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP Report
Release Type: Unrestricted

The VA Office of Inspector General (OIG) evaluated quality of care at the VA Eastern Colorado Health Care System. This included reviews of processes that affect patient care outcomes—Quality, Safety, and Value (QSV); 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 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 138 employees.

OIG identified certain system weaknesses in the QSV Committee; credentialing and privileging; utilization management; patient safety; general safety; environmental cleanliness; reusable medical equipment processes; anticoagulation policies/processes; transfer processes and documentation; point-of-care testing follow-up; moderate sedation data collection and reporting; management of disruptive/violent behavior; RRTP security; and nurse staffing .

As a result of the findings, OIG could not gain reasonable assurance that the facility:

1. Has effective QSV program oversight, policies, and practices

2. Maintains safety by conducting fire drills and maintains clean horizontal surfaces, ventilation grills, floors, and patient nourishment kitchens

3. Reprocesses reusable medical equipment per manufacturer instructions and ensures employee competency

4. Has a comprehensive anticoagulation therapy management program

5. Has safe inter-facility transfer processes

6. Ensures clinicians take action regarding glucose point-of-care testing results

7. Uses data to improve moderate sedation care

8. Has a comprehensive program for managing disruptive/violent behavior

9. Secures the MH RRTP

10. Uses the nurse staffing methodology and conducts annual reassessments

OIG made recommendations in the following eight areas: (1) QSV, (2) Environment of Care, (3) Medication Management, (4) Coordination of Care, (5) Diagnostic Care, (6) Moderate Sedation, (7) Management of Disruptive/Violent Behavior, and (8) MH RRTP. OIG made a repeat recommendation in Nurse Staffing.