Clinical Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California
The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the VA Loma Linda Healthcare System. This included reviews of various aspects of 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; and Management of Disruptive/Violent Behavior. OIG also followed up on recommendations from the previous Combined Assessment Program and Community Based Outpatient Clinic and Primary Care Clinic reviews and provided crime awareness briefings to 557 employees. OIG identified certain system weaknesses in Environment of Care and Infection Control Committees; general safety; anticoagulation processes; transfer documentation; patients’ re-evaluations immediately before moderate sedation procedures; community nursing home clinical visits and oversight committee representation; the disruptive behavior program; and education and counseling of patients with positive alcohol screens. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Manages the environment effectively by documenting and addressing identified deficiencies, taking actions to address high-risk areas for infection prevention, and securing information technology network rooms; (2) Maintains a comprehensive anticoagulation therapy management program; (3) Has an effective inter-facility transfer process to ensure safe patients transfers from the facility; (4) Has a consistent process for re-evaluating patients immediately before moderate sedation is administered; (5) Effectively oversees the community nursing home program; (6) Effectively manages disruptive/violent behavior; (7) Ensures patients with positive alcohol screens receive education and counseling OIG made recommendations for improvement in the following five review areas: (1) Environment of Care, (2) Coordination of Care: Inter-Facility Transfers, (3) Moderate Sedation, (4) Community Nursing Home Oversight, and (5) Management of Disruptive/Violent Behavior. OIG made a repeat recommendation in Alcohol Use Disorder.
Veterans Affairs Office of Inspector General (OIG)
801 I Street North West
Washington, D.C. 20536, United States
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