Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System, California

Report Information

Issue Date
Report Number
18-04671-25
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
25
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Greater Los Angeles Healthcare System, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility did not have a stable leadership team. Upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risks. However, the OIG had concerns regarding the facility’s 17 percent staff vacancies and the multiple deficiencies in the controlled substances inspections program. The OIG noted that leaders need to improve employee satisfaction and trust and patient experiences. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to sustain and improve performance contributing to the facility SAIL “3-star,” Sepulveda’s CLC “5-star,” and West Los Angeles’ CLC “4-star” quality ratings. The OIG issued 25 recommendations for improvement: (1) Quality, Safety, and Value • Peer review and utilization management review processes (2) Environment of Care • Medication and environmental safety • Protection of patient information • Mental health unit panic alarm testing and bathroom faucet safety (3) Controlled Substances Inspections • Controlled substances coordinator’s reports and program oversight • Controlled substances inspectors’ appointments, competencies, and requirements • Monthly controlled substances areas and pharmacy requirements • Pharmacy operations • Override reports review (4) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee requirements

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 that clinicians complete peer reviews for all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services ensures utilization management reviewers complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors reviewers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Patient Care Services makes certain that staff label multidose medication vials with an expiration date upon opening and monitors staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Operations ensures that managers maintain a safe environment in patient care areas and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Operations ensures that San Luis Obispo VA Clinic staff secure laboratory transport bags containing personally identifiable information and monitors staff compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Operations ensures the VA police document response times for panic alarm testing at the locked inpatient mental health unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director for Operations makes certain that bathroom faucets in the inpatient mental health unit are in compliance with the Mental Health Environment of Care Checklist and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the controlled substances coordinator’s monthly summary report includes all discrepancies and findings identified during inspections and monitors coordinator’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that a quality management committee consistently reviews monthly and quarterly controlled substances program trend reports, including discrepancies identified during inspections, and monitors committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors are appointed in writing to a term not to exceed three years and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the controlled substances coordinator performs and documents competency assessments of the controlled substances inspectors annually and monitors controlled substances coordinator’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that controlled substances inspectors complete monthly inspections and physical inventory counts and monitors inspectors’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors program staff’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the controlled substances coordinator refrains from conducting routine inspections and monitors coordinator’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that controlled substances inspectors complete monthly pharmacy inspections and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify that drugs held for destruction are secured and documented during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors verify the inventory count of prescription pads the day of the pharmacy inspection and monitors inspectors’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director guarantees that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff certifies that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that the Women Veterans Health Committee includes required core members, meets at least quarterly, and reports to facility leaders and monitors committee’s compliance.