Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon
Report Number: 17-01740-62 Download
Issue Date: 1/11/2018
City/State: White City, OR
Grants Pass, OR
Klamath Falls, OR
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) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Southern Oregon Rehabilitation Center and Clinics (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Environment of Care; Long-Term Care: Community Nursing Home Oversight; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 64 employees.

The facility has opportunities to improve the stability of executive leadership and patient satisfaction. However, OIG’s review of accreditation organization findings, sentinel events, disclosures, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was generally knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 1-star rating.

OIG noted findings in five areas of clinical operations reviewed and issued eight recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:

(1) Quality, Safety, and Value

• Root cause analyses completion

(2) Medication Management: Anticoagulation Therapy

• Quality assurance data reviews

(3) Environment of Care

• Environment of care rounds attendance

(4) Long-Term Care: Community Nursing Home Oversight

• Oversight committee membership and attendance

• Cyclical clinical visits

(5) Mental Health Residential Rehabilitation Treatment Program

• Weekly contraband inspections

• Closed circuit television surveillance system

• Signage to alert patients and visitors of recording