Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the Washington DC VA Medical Center
Report Number: 17-01757-50 Download
Issue Date: 1/28/2019
City/State: Washington, DC
Camp Springs, MD
Charlotte Hall, MD
Fort Belvoir, VA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a focused evaluation of the Washington DC VA Medical Center. The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections (CLABSI). The OIG also followed up on the Facility’s progress with action plans established for a recent hotline report.

The OIG noted frequent changes with Facility leaders and organizational risks with the lack of evidence of ongoing, coordinated efforts to improve identified deficiencies, employee relations, and patient care. Facility leaders, who were aware of SAIL data, employee/patient survey results, and patient safety indicators, need to take actions that improve care and performance of the Quality of Care and Efficiency metrics that are likely contributing to the current “1-Star” rating.

The OIG noted findings in six processes reviewed and had an incidental finding that significantly impacts quality care. The OIG issued 18 recommendations attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. These are:

(1) QSV

• Peer review and root cause analysis (RCA) action implementation

• Inpatient admissions and continued stay reviews

• Interdisciplinary review of utilization management data

• RCA results feedback

(2) Credentialing and Privileging

• Focused and Ongoing Professional Practice Evaluations

(3) EOC

• Construction site infection prevention

• Sterile supplies

• Environmental cleanliness

• Medical equipment inventory and safety inspections

• Mental Health seclusion room safety

(4) CS Inspection Program

• Physical security

• CS inventory balance adjustment process

• CS Coordinator position description

• Reconciliation of CS returns to pharmacy

(5) Geriatric Evaluations

• Program oversight and evaluation


• Staff education

(7) Timely scanning of patient reports