Amarillo VA Health Care System
Amarillo, Texas
Joint Commission Unannounced Survey
February 19-21, 2014
OME (Home Based Primary Care) Program(s) (3 day survey) included visit to
CBOC
a. Surveyor went on five home visits (2 in Amarillo, 3 in Lubbock). Surveyor reviewed
the following documents:
 Medication Reconciliation
 Care Plans
 Unapproved Abbreviations,
 National Patient Safety Goals as related to HBPC
 Care Coordination
 Home visit schedules per our policy,
 Dietitian, Pharmacy, OT, PT, Social Work progress notes
 Follow up per the care plan.
b. Surveyor requested 2 home oxygen and 2 Coumadin patients as part of her
document tracers to see if they had safety information, evaluations and pertinent labs.
c. During home visits she reviewed the problem list in relation to the assessment done.
d. Emergency Preparedness – Director HPBC reviewed processes followed during last
year’s snow storm. HPBC Director called +150 patients to ensure Veterans were safe.
She started with oxygen patients first and triaged her calls from 7am-7pm.
e. Prosthetics Program – reviewed components of the DME, prosthetics and oxygen
contracts. She was very satisfied with Prosthetic’s quarterly monitoring of the contracts
– beds, ramps, etc. Prosthetics pulls 10 charts per quarter – monitors timeliness, all
orders, requisitions and the receipts. Surveyor asked about sentinel events and they
discussed the RCA process.
f. Surveyor recommended teaching people how to smoke with oxygen, not just discuss
smoking cessation. Surveyor said good things in VA use of green tubing and the in-line
adaptor to prevent fires and explosions.
g. Reviewed Pharmacy – reviewed how med rec was done, how meds dispensed, Look
Alike Sound Alike meds and how they are identified, emergency cache, expiring and
recalled med process, narcotics, med shortages and what we are doing about them.
Asked about errors in HBPC and how it is resolved. Looked at refrigerator in pharmacy
but not the logs. Discussed pharmacist role in HBPC. Asked what in their consultation
do they review or find drug interactions, refills, expired meds, disease issues, and
intervention recommendations.
1
h. EOC – discussed interactions with HBPC, command chain, hazard vulnerability
assessment, civil disturbance preparedness, power stations, cascade call, what we do
for water, etc. if contaminations or systems down.
i. IC discussed interactions with HBPC, monitoring flu shots, bed bug plan, patient
surveillance, add URI to IC Plan. Recommended look at UTIs/Infections with a
denominator of days of care instead of UTI per total number of patients cared for.
j. PI – looked at data collection on falls, outcomes. Surveyor said we have good oxygen
safety information.
k. Competency – primary sourse verification, license current, evaluations,
competencies, orientation as applicable, CPR.
l. Surveyor complimented the Emergency Preparedness Kits, Patients Home folders
with their care plans and emergency information; home flu shot kit, locked boxes in the
Home Health vehicles, new care plan pending approval, the quality of staff and team
coordination.
Findings:


PC.01.03.01 EP 1 & 5 – needed additional care plan information on 2 patients
IC.01.05.01 EP 7 – need handout for Respiratory Hygiene Communication –
suggested a CDC brochure.
Nursing Care Center (NCC) - Long Term Care - 120 bed program (2 day survey)
Tour
Recreation Therapy
 Rec Room – Keys to unlock the Key Box was hanging from the door – The box
contains keys for the cabinets, refrigerator, etc., in the Rec Room
 Activities going on in the commons with good interaction between staff and
residents
 Watched Bingo – impressed with interaction and how many residents attended
the activity.
Crash Cart – opened and examined contest.
Unit CLC-B
 Lifts noted in all hallways but were all to one side. Surveyor told us this would
not be a problem. For future reference only Medicine cart in use; emergency
cart; isolation carts; and housekeeping carts in use are permissible in the
2




hallways. If medical equipment is in the hallway greater than 30 minutes without
being in use, this is considered storage.
Noted memory boxes do not have anything in them.
Noted that fire doors are locked and explained that all staff have a key that fits
these doors and this is part of orientation.
Beds and furniture were in one hallway but explained these rooms were being
terminally cleaned.
Pictures of residents were missing on many of the doors.
Unit CLC-A
 3 broad chairs noted in the dementia unit and not in use. Most of the residents
were in the dining room at the time of our visit.
 Resident’s dryer was filled with lint, and this was corrected on site. Explained the
dryer felt warm so possibly staff was not able to clean this out yet.
 Noted two large trash containers in the hallway. EMS explained one was trash
and one was for dirty diaper. Need to remember to call them briefs. This is a
dignity issue.
 One hall had med cart on one side and other equipment on the opposite side of
the hall. However RN was giving medications at the time and this was noted.
 Surveyor made note of alarms going off and not being answered timely.
 Noted oxygen tank in alcove that was secured to wall. Noted there was not
signage to mark full/empty.
Infection Control
 Outstanding interview
 MRSA Program – talked about prevalence study and why ours was high stating
this was due to age, underlying chronic disease, LT use of antibiotics, and that
our community was also high. Was able to tell the surveyor we had 19 on CLC-A
and 17 on CLC-B.
 Flu Program
 C-Diff – have no cases at the present but if we did would have signage on door,
red tape at doorway, sign on alcohol dispenser not to use but to use soap and
water for hand hygiene and that EMS would be notified.
 VRE – none at present but would use precautions same as C-diff.
 Foley catheter care
 UTIs
 Hand hygiene program with statistics
Safety
 Fall Prevention – was impressed with our explanation and reviewed some notes
when she looked at charts. Identified one issue: notification of family. Stated
would call in the morning but had problem finding were the family had been
notified.
 Medication Errors – asked about rates of fentanyl patches. Liked our
explanation.
3
Care Issues
 Asked how we educated our residents and looked at the documentation.
 Asked about communication from shift to shift and asked if we included CNAs in
reports.
 Asked about nursing vacancies and HPPD.
 Reviewed pain notes for assessment and reassessment. Veteran had scheduled
narcotics.
 Asked about Pressure Ulcers and to see documentation on residents with PU.
 Asked to see the youngest Veteran resident’s record and recreation plan.
Requested policy on H&Ps in the CLC.
Miscellaneous Questions:
 Asked about culture and how we worked together
 Asked about the primary language of our residents and if this was English. All
but 1 Veteran has primary language as English.
 Asked if we had a dietician and if they were assigned to the CLC and their
involvement.
Requests:
 Policy for the medical providers H&P
 Gave NM a list of staff for review to include:
o Recent competencies
o License
o Performance evaluation
o CPR record
o 2 forms of blood glucose competency
 Orientation for staff
RAI/MDS and PI
Monthly issues discussed by IDCP team:
 Hydration
 Pressure ulcer
 Falls
 Infection Control
 Unexplained injuries
 Medication review and antipsychotic reviews
Competency Folders
Reviewed folders for RN, LVN, CAN, Rec Therapist, SW and Dietician.
Dementia Unit and Rehab
 Looked at activities going on in the unit.
 Looked at refrigerator and freezer
 Reviewed temp monitors and suction machine in dining area
4

Looked at OT & PT rooms on the unit. Staff able to articulate the process of how
Recreation and Rehab work together.
Findings: EC.02.06.01 EP 1 - Define areas (signage) for full and empty 02 Cylinders.
Behavioral Health (3 day survey)
How does the VA monitor contracts to ensure that quality of care is provided to our
veterans?
Requested contracts for review:
 Halfway house contract – suggested clearly spell out VA expectations in the
contract. List of deliverables on how they are being monitored to ensure they are
being done.
 Other facilities we send Veterans to do not have contract or MOU. Chief, Mental
Health Services reported the only agreement with these facilities specified that
VA MH suicide prevention staff is to have access to the veteran.
Findings:
CTS.01.04.01 EP 1 – Need Psychiatric Advance Directives x 2
CTS.02.03.07 EP 1, 6 & 9 – No clear assessment of the duration and patterns of use for
those substances identified as having been abuse. Assessment did not explore the
veteran’s perception of the role of spirituality or religion his/her life. Assessment did not
include a clear relapse history for the drugs and alcohol identified as his drugs of abuse
including cocaine, alcohol and meth.
CTS.03.01.03 EP 6 – Vocation services and recreation/peer support services not
documented in updated treatment plans.
HAP (3 Day Survey) included visits to two CBOCs by Administrator/Ambulatory
Surveyor
Life Safety Surveyor (2 Day Survey
Some of the issues found:






Electrical panel inspections revealed that there were multiple versions of
schedules.
OI&T wiring/cables strapped to fire suppression lines and supporting hanger
rods.
Several open electrical junction boxes were discovered
Ice machine had calcium buildup at dispensing shield and seems to have growth
on it
Blocked medical gas shutoff panels in OR Suite
Storage room had a dirty diffuser and dirty sprinkler head
5





Power strips lying on the floor should be mounted or installed in a manner where
they are not on the floor.
Storage under sink in refreshment area.
Storage under sink in PACU/DSU near ice machine
Medical Equipment inspection out-of-date (2 blood pressure machines) locked
away in storage room and was not turned in for trade-in with newer machines.
Smoke wall barrier penetration.
Administrator/Ambulatory Surveyor:
Dental Clinic:
How long to get an appointment for preventative care?
How long to get follow up work done?
How long to get emergent/urgent care?
How long to get dentures made?
What is produced in the dental lab?
Dental Lab eye wash checked.
Asked about how many dentists, hygienists, etc. on staff here and at CBOC.
Asked about credentialing for hygienists.
Asked about sterilization of instruments – SPS does all sterilization.
How are patients identified? Full SSN and full name
Medication security – all secure.
Check Crash Cart – Dental does not check crash cart – Pharmacy does. Asked who
responds to codes in dental – Code Team. Asked about mock code drill in Dental –
none. Asked about operational status of equipment on cart – dental didn’t know –
Pharmacy checks cart.
Infection control – checked clean/dirty linen and equipment rooms. Asked about how
equipment gets from one to other and how new supplies are delivered and dirty items
removed.
Staff able to verbalize how performance is monitored and PI monitors.
Asked about Dental X-Rays, radiation badges and aprons checks.
Respiratory Therapy




How are orders received and how is it documented that RT work is done?
How do you know that pharmacy has reviewed the order before the treatment is
given?
How meds are distributed on rounds was described?
Who is the physician providing outsight for RT?
6







RT responds to all codes and rapid responses.
Ventilators: 3-4 per month, there is enough staff and equipment to meet needs.
Any adjustment to ventilators is done by RT after physician orders – RNs do not
adjust ventilators.
Cleaning of ventilators: Most parts disposable, machine wiped down
appropriately, stored in ICU.
Patients on CPAP – patients bring their own machines or one provided
(disposable parts, machine wiped down appropriately).
PFT Access – work in on same day
Oxygen storage checked.
Clovis CBOB












Lab:











Asked about services provided, number of rooms for each service, audio privacy
for MH, and depth of lab services.
Telehealth process explained
Access to care for routine primary care
Access to care for routine MH service (urgent cases and walk-ins explained)
How is hand hygiene monitored – patient survey
Asked about facility security – emergency – 911, cameras monitored by Amarillo
VA police
Dietitian needs – met by HPDP program from Lubbock CBOC
Emergency Management: Fire drills conducted locally – process explained –
Severe weather drills run by Amarillo EM staff – recommend bringing AED to
shelter area and having access to medical supplies in case of injuries;
New Employee Orientation – done by Amarillo VA
EOC rounds – done by Amarillo VA
Fire extinguisher inspections – done on EOC rounds
Amarillo lab visits monthly
Eye wash log
What happens to specimens drawn in lab – courier to Amarillo
Process for drawing blood explained
AED checks – Amarillo BioMed checks, local inspections?
A veteran was asked how long he has to wait in the waiting room
Oxygen storage
clean/dirty linen
medication storage
Asked about AccuCheck equipment – stated that once the agents were opened
they were dated “for 30 days”.
Chart Reviews
7

Asked about Advance Directives, specifically, after one has been completed how
often is it revisited for accuracy? No specific JC standard but perhaps annually
would be better, concerned about uniformity in this area.
Lubbock CBOC:
Asked about services offered, staff, space and equipment sufficiency
Primary Care:
 Asked if waiting room time is tracked
 Medication storage – security okay
 Oxygen storage
 Fire extinguishers
 Fire Drills – Documentation process. Assembly area after evacuation – unclear.
 Severe weather drills
 Other EM drills – may consider combining a couple together to ensure all of the
drills get run more often, ie: fire drill and bomb threat together.
 AED – In-house codes are called “Nurse Stat”, 911 called if needed.
 Med Equip: Amarillo Biomed does annual inspections and maintenance. If
needed, local contract for quarterly PM.
 What do you do if the tag is out of date?
 Specialty Care: wait time 2-3 months
 Med cart inspection. Contents, eye wash
 Sterile Processing: Process, Recordkeeping, workflow, number of instruments,
eyewash. May want to install a visual pressure indicator to show pos/neg air
pressure
 Dental: Access – a couple of weeks, unless emergent
 Med storage, okay. Instrument storage
Dental Lab:
 Turnaround time – 2 to 3 weeks.
 Eyewash
Lab: Phlebotomy process. Vacutubes - Red bag waste. Eyewash Critical values
reporting process.
Radiology: one machine, one tech
Lead shields: thyroid shield not marked, no record of testing for serviceability; ultimately
not on VA inventory at all. Records for testing lead aprons not kept on site (AVAHCS)
Badge exchange and testing process okay, but reporting of results unclear
PT – including chart review
MH – auditory privacy. Group therapy and 1 to 1 therapy
One emergency hallway light broken
8
Amb. Care Chart review (x2)
Nurse (Team Leader)
Tracer – Pt left total knee:
 Checked for H&P
 Interim H&P
 Advanced Directive paperwork
 Pre-op Assessment in surgical admission note (fall risk, functional assessment,
surgery care plan)
 Med Rec verified.
 Reviewed nursing care plan
 One concern – no specific monitoring of incision for infection
 PRN med found with no indication for use (tramadol).
 Surgery consent and brief op note were all present. Mallapati score was found in
PACU note and ASA class on anesthesia note.
Record review/tracers:
 PRN meds are consistently not stated for what the PRN med is for, IE: is the
Tylenol for HA, Fever, etc.
 Respiratory Patient:
o Checked for DNR
o Pt on CPAP
o Skin assessment – abrasions/bruising on chest and arm noted. How do
you know these are not signs of abuse? Asked Patient and Family.
Surveyor do you think if the ones answering would tell if they were
responsible for the abrasions/bruising?
o Patient on hand held nebulizer treatments - who gives these to patient?
Respiratory. What if Respiratory does not come? Nursing gives
treatment. Do you have training on giving nebulizer treatments? Yes
competency training.
 Telemetry – Who monitors telemetry? Is it at desk on floor? Is there a telemetry
bank where someone sits and watches? Does the monitor clerk watch all
telemetry for entire hospital? How many or how often does monitor clerk get
breaks and who monitors while they are gone? What if person called by monitor
clerk not answering phone?
 All restraint orders and documentation present
 Surveyor did not like that form used for restraint documentation does not include
fields for location of restraints. This should be included on the form because it
makes it difficult to ascertain whether the nurse followed the restraint order.
 Autopsy record review no findings
 Patient Grievances – lack of clearly documented follow up per our policy.
 IC tracer – no findings during meetings or during tracer. Surveyor took time to
compliment EMS on thoroughness of room cleaning.
9
Canteen –
 Requested review of cleaning logs a policy for ice machine. Ice machine is not
used for consumption but for salad bar. NO MCM and last cleaning in April 2013.
Manufacturer’s guidelines recommend annual cleaning and this satisfied the
surveyor.
 Cases of water bottles (in cardboard) were noted sitting on the floor.
 Cheese was found in the refrigerator and was not labeled per policy signage
hanging on the refrigerator door.
N&FS
 Expired milk found in refrigerator. Milk was stored with unexpired milk and had
no signage (DO NOT DISTRIBUTE) on it. Expired milk held until vendor picked
up for credit.
 Temp logs were checked and surveyor was concerned that Blast Chiller was
noted to be “off” on the log but was currently in use during time of inspection.
Staff verbalized that they only document temperature if machine is in use during
time of rounds.
Competency – Nursing
 1 folder had a performance evaluation done about 4 months after the previous
year’s date.
 Primary source verification had no issues.
 It was observed that the scanning date in VETPRO is the date defaulted to
verification. One staff had source verification check on 10/1/13 and license
expired on 10/31/13. The staff member worked night shift on 10/31/13 and
VETPRO for October was entered on November 1, 2013.
Physician
ICU



Code carts check – suggested serial numbers on the locks and check the
numbers every time you check the cart.
Checked clean linen room
Checked break rooms for PHI
ENDO
 Sharps container has big opening and saw medication vials in it – requested to
verify the vials were empty – stated this was a good way to divert medications.
Suggested smaller opening sharps container.
 Checked DNR
 Check for flu shot
CBOC
10


Verify vaccines in the CBOC’s have not been compromised – how do you know if
the refrigerator was at the desired temp range in the middle of the night? Backup
generator for the CBOC?
Asked about Profofal and Succ in the Ed and ICU-who had privileges?
Inpatient
 Asked for last 3 months of inpatient deaths
 Inpatient which required a transfer to a higher level facility
 CVA which required a transfer to a higher level facility
Pharmacy
 Asked was pharmacy open for 24 hours – who has access after-hours?
 Asked about the Cache – what do we do with the expired drugs?
 IV admixtures – policy, competencies, education (for nursing)
 High risk medications – heparin gtt – are we monitoring lab times, medication
change times to determine accuracy
Critical Labs – do we monitor for low lab values?
ED – unmonitored waiting rooms
 High risk patient – documented education for all staff on how to handle them
 Lidocaine in a chest tube tray – how do you track the lot numbers on the
lidocaine?
 Transcription of H&P from ED physician a problem due to the admitting physician
cannot view unsigned notes.
Credentialing
 How do you track license expirations?
 Contract physicians – OPPE data on them
 Need clinical data on the OPPE
 How often are privileges reviewed for services that have not been done in years?
 What is your process when there is not data?
 Emergency Management privileges for the EM plan?
Emergency Management
 Looked at high risk medications like chemo and heparin
 Reviewed process for handling chemo drugs
Leadership Session
 Ask about high reliability
 Never Events
 How do you deal with hand off communication for example ED to Floor
 How do you know when your processes work?
 Contracts – Quality of the service
 How do you evaluate your leadership?
11
Findings:
EC.02.02.01 EP 7 – Thyroid radiation shield in CBOC not uniquely identified to assure
its inclusion into the radiation protective lead inventory.
EC.02.03.01 EP 1- Missing Electrical J-Box covers
EM.02.02.13 EP 5 – LIP Volunteer Practitioner
EC.02.04.03 EP 3 – Monitor without current PM
EC.02.04.09 EP 3 – Medical gas zone blocked by equipment
EC.02.06.01 EP 1 – Unmarked holder for empty 02 Cylinder
IC.02.02.01 EP 4 – Cabinet where endoscopes stored not tall enough
LD.04.01.07 EP 2 – Patient complaint process
LS.02.01.35 EP 3,4,5 – Sprinkler system
MS.08.01.03 EP 1 – OPPE/FPPE
PC.02.02.03 EP 6 – Outdated milk
RC.01.01.01 EP 11 – Paper records in ED sign, date, and time per local policy.
12