Combined Assessment Program Summary Report - Evaluation of Selected Requirements in Veterans Health Administration Community Living Centers

Report Information

Issue Date
Report Number
15-01721-382
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the evaluation was to determine whether facilities complied with selected restorative nursing and dining requirements to assist community living center residents in maintaining their optimal level of functioning, independence, and dignity. The VA Office of Inspector General (OIG) conducted this review at 47 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2013, through September 30, 2014. Although OIG noted high compliance in many areas, including provision of assistive eating devices to residents during meals, dining atmosphere, and honoring residents’ preferences, OIG identified opportunities for Veterans Health Administration facilities to improve and made seven recommendations.

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)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents who may be candidates for restorative nursing services, the interdisciplinary team documents the reason the resident is not receiving the services or other activities to promote functional status.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents receiving or supposed to receive restorative nursing services, the interdisciplinary team documents goals in their care plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that nursing employees provide and document restorative nursing services in accordance with the care plan, and if they do not provide the services, they document the reason.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees complete required restorative summary notes and that the Associate Chief Nurse or designee monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents not progressing toward restorative goals, the interdisciplinary team reassesses the resident care plan and/or adjusts goals and interventions as necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that Physical Medicine and Rehabilitation therapists discharging residents from therapy document hand-off communication with nursing employees to ensure interventions continue or are discontinued, as applicable.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility managers provide and document nursing employee training on range of motion and transfers.