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Inspection of Sterile Processing Services at the Carl T. Hayden VA Medical Center in Phoenix, Arizona

Report Information

Issue Date
Report Number
21-02489-69
VISN
22
State
Arizona
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Major Management Challenges
Healthcare Services
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning Sterile Processing Services (SPS) at the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona. The OIG substantiated that SPS staff failed to don personal protective equipment (PPE) in SPS decontamination areas. The OIG observed SPS and other facility staff enter decontamination areas without required PPE. The OIG did not substantiate that SPS staff falsified Resi-Tests by documenting the same lot number for endoscopes. The OIG found that some Resi-Test kits had the same lot numbers but that was not indicative of falsified tests. Additionally, the OIG identified missing documentation of Resi-Test results from October through December 2020; however, based on review of subsequent documentation, direct observations, and interviews, the OIG concluded that SPS staff completed Resi-Tests in accordance with policy. The OIG did not substantiate that SPS staff failed to follow validation testing requirements for biological indicators and Bowie-Dick tests for sterilizers. The OIG found no infection concerns associated with inadequate reprocessing of equipment. The OIG found that SPS staff followed reprocessing steps according to standard operating procedures and instructions for use. The OIG did not substantiate that SPS staff did not have adequate reprocessing supplies. The OIG found that floor grade instruments received in decontamination areas were discarded and not reprocessed. The OIG found that SPS staff reviewed instructions for use for loaner trays upon receipt at the facility. The OIG did not substantiate that SPS staff failed to receive documentation for instruments sterilized at another VA facility. The OIG concluded that SPS leaders were knowledgeable of the practice standards. The OIG made one recommendation to the Facility Director to ensure staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.

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 Carl T. Hayden VA Medical Center Director ensures that staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.