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Comprehensive Healthcare Inspection Program Review of the Roseburg VA Health Care System, Oregon

Report Information

Issue Date
Report Number
18-00620-277
VISN
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Roseburg VA Health Care System (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Facility has been and continues to be in transition. Three of the four executive leaders were new to their positions, and two were in temporary assignments. Facility challenges including ineffective leadership, toxic culture, personnel practices, and improper admission practices have been reported by media and were the subject of recent internal and external evaluations. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. However, the OIG identified concerns with hydromorphone (pain medication) shortages, gaps in provider privileging processes, and inadequate tracking and monitoring of On-demand supplies. The senior leadership team appeared aware of the magnitude of the challenges and were taking action to restore a culture of trust, increase employee and patient satisfaction, and improve the quality of care and efficiency metrics contributing to the “1-Star” rating. The OIG noted findings in three of the seven areas of clinical operations reviewed and issued seven recommendations that are attributable to the Interim Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations processes (2) Environment of Care • Storage of cleaning solutions in food preparation areas (3) Medication Management: CS Inspection Program • CS monthly inspections • CS reconciliation

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)
The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly defined timeframes and monitors the clinical managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Focused Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that the Executive Council of Medical Staff uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures Nutrition & Food Service staff store cleaning solutions separately from food items and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Interim Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and that controlled substances coordinators refrain from conducting routine inspections and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Interim Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.