Healthcare Inspection Community Based Outpatient Clinic Reviews Smithville, MS and Memphis (Memphis-South), TN Knoxville, TN and Norton, VA Chattanooga and Nashville (Vine Hill), TN

The VA Office of Inspector General reviewed six Community Based Outpatient Clinics (CBOCs) the week of March 15–19, 2010. The CBOCs reviewed in Veterans Integrated Service Network (VISN) 9 were Smithville, MS and Memphis (Memphis-South), TN; Knoxville, TN and Norton, VA; and Chattanooga and Nashville (Vine Hill), TN. The parent facilities of these CBOCs are Memphis VA Medical Center (VAMC), Mountain Home VAMC, and Tennessee Valley Health Care System (HCS)-Nashville, respectively. The purpose of the review was to assess whether CBOCs are operated in a manner that provides veterans with consistent, safe, high-quality health care. The review covered five areas: quality of care measures, credentialing and privileging, environment of care and emergency management, suicide safety plans, and CBOC contracts. We noted several opportunities for improvement and made the following recommendations to the VISN and facility management: Ensure practitioners practicing under Scopes of Practice are monitored according to policy. Grant privileges that are consistent with CBOC providers’ practices. Ensure the Infection Control program includes a hand hygiene component. Require that medical record documentation be in compliance with Veterans Health Administration (VHA) policy. Secure and protect all personally identifiable information. Ensure staff receives education and training related to the panic alarm system. Maintain auditory privacy during the check-in process. Perform a vulnerability risk assessment to address potential workplace risks. Ensure that all patient care areas meet safety criteria. Require annual fire safety drills and inspections. Enforce the use of two patient identifiers in the blood drawing process. Ensure the Contractor inspects for cleanliness and performs needed repairs. Develop a local policy or standard operating procedure that reflects the current practice and capability for handling medical and mental health emergencies. Ensure the local safety plan policy is in compliance with VHA policy. Provide contract oversight and enforcement in accordance with the terms and conditions as stated in the contract. Research the overpayments attributable to duplicate enrollees and seek refunds for those overpayments. Make sure the Primary Care Management Module Coordinator performs in accordance with VHA Handbook 1101.02 to ensure accuracy of data reported to the VAMC and to the VHA Support Service Center. Re-compete the contract if planning to continue to offer contracted primary care services. Draft a new contract to ensure compliance with terms during the re-compete process so as not to disrupt care to veterans. Provide contract oversight and enforcement in accordance with the terms and conditions as stated in the contract, specifically that a medical evaluation is performed at least once in 12 months. Take steps to recover overpayments on invoices.