Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Corporal Michael J. Crescenz VA Medical Center, 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’s executive leadership team had worked together for one month, except for the assistant director who was on detail prior to and through the OIG’s on-site visit. The OIG found the facility average for several selected survey leadership questions were generally similar or better than the VHA average. One of four patient survey results reflected better care ratings than the VHA average. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was generally knowledgeable within their scope of responsibility, and time in their positions, about selected SAIL and CLC metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “3-star” and CLC “2-star” quality ratings. The OIG issued six recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused professional practice evaluation process (2) Medication Management: Controlled Substances Inspections • Inventory balance adjustment processes (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee processes • Patient notification of abnormal results

This audit is part of a series of hospital compliance audits. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2017, Medicare paid hospitals $206 billion, which represents 55 percent of all fee-for-service payments for the year.

This review is part of a series of hospital compliance reviews. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2017, Medicare paid hospitals $206 billion, which represents 55 percent of all fee-for-service payments for the year.

This review is part of a series of hospital compliance reviews. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2017, Medicare paid hospitals $206 billion, which represents 55 percent of all fee-for-service payments for the year.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that a patient “may have died wrongfully” by aspiration during resuscitation attempts, and that the patient had a Do Not Attempt Resuscitation (DNAR) order but resuscitation was attempted at the Baltimore VA Medical Center (facility), Maryland. The OIG identified concerns related to DNAR documentation and communication, follow-up on a patient safety concern related to medication contraindications, and code blue documentation. The OIG substantiated that the patient died due to aspiration pneumonia, and subsequent cardiopulmonary arrest, and that facility staff attempted resuscitation. The OIG was unable to determine if the cause of death was wrongful. The OIG substantiated that facility staff attempted resuscitation on a patient with a DNAR status; however, there was no DNAR order when resuscitation was attempted. The OIG determined that residents and physicians did not comply with documentation requirements for DNAR orders and DNAR progress notes and failed to effectively communicate the DNAR status to team members. The absence of physician DNAR orders and progress notes, the presence of full code orders in telemetry order sets, and the lack of physician communication regarding DNAR status to the nursing staff resulted in the healthcare team not having the information needed to appropriately intervene when the patient became unresponsive. The OIG found that facility leaders failed to act on an identified pharmacy safety issue related to the administration of haloperidol in patients with Parkinson’s disease. The issue was not addressed until the OIG requested an update in February 2019. The OIG found facility staff did not comply with code blue documentation requirements. The facility’s measures to identify and rectify challenges with resuscitation processes were insufficient. Facility leaders failed to hold clinical staff responsible for code blue documentation. The OIG made four recommendations.