Comprehensive Healthcare Inspection of the Lexington VA Health Care System in Kentucky

Report Information

Issue Date
Report Number
21-03308-24
VISN
9
State
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient settings of the Lexington VA Health Care System and associated outpatient clinics in Kentucky. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (emergency department and urgent care center prevention initiatives) The OIG issued 10 recommendations for improvement in four areas: 1. Quality, safety, and value • Peer review improvement actions 2. Medical staff privileging • Focused and Ongoing Professional Practice Evaluations 3. Environment of care • Local naloxone policy • Product expiration dates • Furnishing safety and condition • Suicide risk abatement plans 4. Mental health • Suicide risk screening

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 Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs’ determinations to continue current privileges are based on Ongoing Professional Practice Evaluation activities.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Committee’s decision to recommend continuation of privileges is based on Ongoing Professional Practice Evaluation results.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures staff have a current local intranasal naloxone policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain managers adhere to commercial product expiration dates in the community living center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures managers keep furnishings safe and in good repair.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff develop abatement plans to minimize risks for suicide and suicide attempts in acute inpatient mental health units.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete 100 percent of required universal and setting-specific screenings and Comprehensive Suicide Risk Evaluations.