Clinical Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky

The VA Office of Inspector General (OIG) conducted an evaluation of the Lexington VA Medical Center. This included key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care, Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; Management of Disruptive/Violent Behavior; and Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP). OIG provided crime awareness briefings to 295 employees. OIG identified certain system weaknesses in utilization management; general safety and security; cleanliness; reusable medical equipment reprocessing and competencies; bloodborne pathogens training; anticoagulation policy, procedures, and competencies; transfer documentation; moderate sedation practices and training; community nursing home program oversight; disruptive/violent behavior management and training; MH RRTP privacy; and MH unit panic alarm testing. As a result of the findings, OIG could not gain reasonable assurance that: (1) Physician advisors document utilization management decisions; (2) The facility has effective reusable medical equipment reprocessing processes and a clean and safe reprocessing environment; (3) The Cooper Division maintains clean ventilation grills and monitors after-hours visitors; (4) Hemodialysis unit employees receive bloodborne pathogens training; (5) Anticoagulation policies include requirements, employees review quality assurance data, and competency assessments include all elements; (6) Transfer notes contain required elements; (7) Moderate sedation clinicians safely discharge outpatients and have current training; (8) Facility leaders monitor the community nursing home program; (9) Disruptive/violent behavior is managed, and employees receive training; (10) The facility maintains MH RRTP privacy and has a safe MH unit environment. OIG made recommendations in the following eight areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Moderate Sedation; (6) Community Nursing Home Oversight; (7) Management of Disruptive/Violent Behavior; and (8) MH RRTP. OIG made a repeat recommendation for panic alarm testing.