jurisdiction: US

text: b' Department of Veterans Affairs\n Office of Inspector General\n\n\n Office of Healthcare Inspections\n\nReport No. 13-03416-56\n\n\n Community Based Outpatient Clinic \n\n and Primary Care Clinic Reviews \n\n at \n\n VA Montana Health Care System \n\n Fort Harrison, Montana \n\n\n\n\n\nFebruary 5, 2014\n\n Washington, DC 20420\n\x0cTo Report Suspected Wrongdoing in VA Programs and Operations \n\n Telephone: 1-800-488-8244 \n\n E-Mail: vaoighotline@va.gov\n\n (Hotline Information: www.va.gov/oig/hotline)\n\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n Glossary\n ADA Americans with Disabilities Act\n AED automated external defibrillator\n AUD alcohol use disorder\n CBOC community based outpatient clinic\n DWHP designated women\xe2\x80\x99s health provider\n EHR electronic health record\n EMC Emergency Management Committee\n EMP Emergency Management Plan\n EOC environment of care\n FY fiscal year\n IT information technology\n MH mental health\n MI motivational interviewing\n MM medication management\n NA not applicable\n NIAAA National Institute on Alcohol Abuse and\n Alcoholism\n NM not met\n OIG Office of Inspector General\n PACT Patient Aligned Care Team\n PCC primary care clinic\n PCP primary care provider\n PII personally identifiable information\n RN registered nurse\n VHA Veterans Health Administration\n VISN Veterans Integrated Service Network\n WH women\xe2\x80\x99s health\n\n\n\n\nVA OIG Office of Healthcare Inspections\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n Table of Contents \n\n Page \n\nExecutive Summary ................................................................................................... i\n\n\nObjectives, Scope, and Methodology....................................................................... 1\n\n Objectives ............................................................................................................... 1\n\n Scope...................................................................................................................... 1\n\n Methodology ........................................................................................................... 1\n\n\nResults and Recommendations ................................................................................ 3\n\n EOC ........................................................................................................................ 3\n\n AUD ........................................................................................................................ 6\n\n MM .......................................................................................................................... 8\n\n DWHP Proficiency .................................................................................................. 9\n\n\nAppendixes\n A. CBOC Profiles and Services Provided .............................................................. 10\n\n B. PACT Compass Metrics .................................................................................... 13\n\n C. VISN Director Comments .................................................................................. 17\n\n D. Facility Director Comments ............................................................................... 18\n\n E. OIG Contact and Staff Acknowledgments ......................................................... 24\n\n F. Report Distribution ............................................................................................. 25\n\n G. Endnotes ........................................................................................................... 26\n\n\n\n\n\nVA OIG Office of Healthcare Inspections\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n Executive Summary \n\nReview Purpose: The purpose of the review was to evaluate selected patient care\nactivities to determine whether the community based outpatient clinics (CBOCs) and\nprimary care clinic (PCC) provide safe, consistent, and high-quality health care for our\nveterans. We conducted site visits during the week of November 4, 2013, at the\nfollowing CBOCs which are under the oversight of the VA Montana Health Care System\nand Veterans Integrated Service Network 19:\n\n\xef\x82\xb7 Cut Bank CBOC, Cut Bank, MT\n\n\xef\x82\xb7 Miles City CBOC, Miles City, MT\n\nReview Results: We conducted four focused reviews and had no findings for the\nDesignated Women\xe2\x80\x99s Health Providers\xe2\x80\x99 Proficiency review. However, we made\nrecommendations in the following three review areas:\n\nEnvironment of Care. Ensure that:\n\n\xef\x82\xb7\t Access to the clinic and the restroom are compliant with the Americans with\n Disability Act.\n\n\xef\x82\xb7\t Hazardous materials inventory reviews occur twice within a 12-month period at the\n Cut Bank and Miles City CBOCs.\n\n\xef\x82\xb7\t Signage identifying the location of fire extinguishers and exits is installed at the Cut\n Bank CBOC.\n\n\xef\x82\xb7\t Information Technology (IT) server closets at the Cut Bank and Miles City CBOCs\n are maintained according to IT safety and security standards.\n\n\xef\x82\xb7\t Computer screens are secured to eliminate viewing of personally identifiable\n information at the Miles City CBOC.\n\n\xef\x82\xb7\t An AED is available at the Miles City CBOC.\n\n\xef\x82\xb7\t Parent facility documents Emergency Management Preparedness-specific training\n completed for the clinical providers at the Cut Bank and Miles City CBOCs.\n\n\xef\x82\xb7\t Parent facility\xe2\x80\x99s Emergency Management Committee evaluates the Cut Bank and\n Miles City CBOCs\xe2\x80\x99 emergency preparedness activities, participation in annual\n disaster exercises, and staff training/education relating to emergency preparedness\n requirements.\n\n\n\n\nVA OIG Office of Healthcare Inspections i\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nAlcohol Use Disorder. Ensure that CBOC/PCC:\n\n\xef\x82\xb7\t Staff consistently document diagnostic assessments for patients with a positive\n alcohol screen.\n\n\xef\x82\xb7\t Staff provide education and counseling regarding the National Institute on Alcohol\n Abuse and Alcoholism limits for patients with positive alcohol screen.\n\n\xef\x82\xb7\t Staff consistently document the offer of further treatment to patients diagnosed with\n alcohol dependence.\n\n\xef\x82\xb7\t Registered Nurse Care Managers receive motivational interviewing training within 12\n months of appointment to Patient Aligned Care Teams.\n\nMedication Management. Ensure that CBOC/PCC staff:\n\n\xef\x82\xb7\t Document medication reconciliation that includes the newly prescribed\n fluroquinolone in the electronic health record.\n\n\xef\x82\xb7\t Provide medication counseling/education that includes fluoroquinolones.\n\n\xef\x82\xb7\t Document the evaluation of patient\xe2\x80\x99s level of understanding for medication\n education.\n\nComments\nThe VISN and Facility Directors agreed with the CBOC and PCC review findings and\nrecommendations and provided acceptable improvement plans. (See Appendixes C\nand D, pages 17\xe2\x80\x9318, for the full text of the Directors\xe2\x80\x99 comments.) We consider\nrecommendation 6 closed. We will follow up on the planned actions for the open\nrecommendations until they are completed.\n\n\n\n\n JOHN D. DAIGH, JR., M.D.\n Assistant Inspector General for\n Healthcare Inspections\n\n\n\n\nVA OIG Office of Healthcare Inspections ii\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n Objectives, Scope, and Methodology \n\nObjectives\nThe CBOC and PCC reviews are an element of the OIG\xe2\x80\x99s efforts to ensure that our\nNation\xe2\x80\x99s veterans receive high-quality VA health care services. As such, the CBOC and\nPCC reviews are recurring evaluations of selected primary care operations that focus on\npatient care quality and the EOC. In general, our objectives are to:\n\n \xef\x82\xb7\t Determine whether the CBOCs are compliant with EOC requirements.\n\n \xef\x82\xb7\t Determine whether CBOCs/PCCs are compliant with VHA requirements in the\n care of patients with AUD.\n\n \xef\x82\xb7\t Determine compliance with requirements for the clinical oversight and patient\n education of fluoroquinolones for outpatients.\n\n \xef\x82\xb7\t Evaluate if processes are in place for DWHPs to maintain proficiency in WH.\n\nScope\nTo evaluate for compliance with requirements related to patient care quality and the\nEOC, we conducted onsite inspections, reviewed clinical and administrative records,\nand discussed processes and validated findings with managers and employees. The\nreview covered the following four activities:\n\n \xef\x82\xb7\t EOC\n\n \xef\x82\xb7\t AUD\n\n \xef\x82\xb7\t MM\n\n \xef\x82\xb7\t DWHP Proficiency\n\nThe scope of this review is limited to the established objectives. Issues and concerns\nthat come to our attention that are outside the scope of this standardized inspection will\nbe reviewed and referred accordingly.\n\nMethodology\nThe onsite EOC inspections were only conducted at randomly selected CBOCs that had\nnot been previously inspected.a Details of the targeted study populations for the AUD,\nMM, and DWHP Proficiency focused reviews are noted in Table 1.\n\n\n\n\na\n Includes 93 CBOCs in operation before March 31, 2013.\n\n\nVA OIG Office of Healthcare Inspections 1\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nTable 1. CBOC and PCC Focused Reviews and Study Populations\n\n Review Topic Study Population\n AUD All CBOC and PCC patients screened within the study period\n of July 1, 2012, through June 30, 2013, and who had a positive\n AUDIT-C scoreb and all providers and RN Care Managers\n assigned to PACT prior to October 1, 2012.\n MM All outpatients with an original prescription ordered for one of\n the three selected fluoroquinolones from July 1, 2012, through\n June 30, 2013.\n DWHP Proficiencies All WH PCPs designated as DWHPs as of October 1, 2012,\n and who remained as DWHPs until September 30, 2013.\n\nIn this report, we make recommendations for improvement. Recommendations pertain\nto issues that are significant enough to be monitored by the OIG until corrective actions\nare implemented.\n\nThe review was done in accordance with OIG standard operating procedures for CBOC\nand PCC reviews.\n\n\n\n\nb\n The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkers or have active\nalcohol use disorders. Scores range from 0-12.\n\n\nVA OIG Office of Healthcare Inspections 2\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n Results and Recommendations \n\nEOC\nThe purpose of this review was to evaluate whether CBOC managers have established and\nmaintained a safe and clean EOC as required.1\n\nWe reviewed relevant documents and conducted physical inspections of the Cut Bank and Miles\nCity CBOCs. The table below shows the areas reviewed for this topic. The areas marked as\nNM did not meet applicable requirements and needed improvement.\n\nTable 2. EOC\n\n NM Areas Reviewed Findings\n The CBOC\xe2\x80\x99s location is clearly\n identifiable from the street as a VA\n CBOC.\n The CBOC has interior signage available\n that clearly identifies the route to and\n location of the clinic entrance.\n X The CBOC is ADA accessible. The handicapped accessible restroom door\n hardware at the Cut Bank CBOC was\n difficult to grasp with one hand and required\n tight grasping, pinching, or twisting of the\n wrist to operate.\n\n The handicapped accessible door accessed\n via the ramp from the Cut Bank CBOC\n parking lot into the lobby was difficult to\n grasp with one hand and required tight\n grasping, pinching, or twisting of the wrist to\n operate.\n The furnishings are clean and in good\n repair.\n The CBOC is clean.\n X The CBOC maintains an inventory of The CBOC\xe2\x80\x99s inventory of hazardous\n hazardous materials and waste that it materials at the Cut Bank and Miles City\n uses, stores, or generates. CBOCs was reviewed for accuracy annually\n rather than twice within the prior 12 months.\n An alarm system and/or panic buttons are\n installed in high-risk areas (e.g., MH\n clinic).\n Alcohol hand wash or soap dispenser\n and sink are available in the examination\n rooms.\n Sharps containers are secured.\n\n\nVA OIG Office of Healthcare Inspections 3\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n NM Areas Reviewed Findings\n Safety needle devices are available.\n The CBOC has a separate storage room\n for storing medical (infectious) waste.\n The CBOC conducts fire drills at least\n every 12 months.\n Means of egress from the building are\n unobstructed.\n Access to fire alarm pull stations is\n unobstructed.\n Access to fire extinguishers is\n unobstructed.\n X The CBOC has signs identifying the There were no signs identifying the location\n locations of fire extinguishers. of one fire extinguisher at the Cut Bank\n CBOC.\n X Exit signs are visible from any direction. There were no exit signs identifying one\n means of egress at the Cut Bank CBOC.\n No expired medications were noted\n during the onsite visit.\n All medications are secured from\n unauthorized access.\n PII is protected on laboratory specimens\n during transport so that patient privacy is\n maintained.\n Adequate privacy is provided to patients\n in examination rooms.\n Documents containing patient-identifiable\n information are not laying around, visible,\n or unsecured.\n Window coverings provide privacy.\n The CBOC has a designated examination\n room for women veterans.\n Adequate privacy is provided to women\n veterans in the examination room.\n X The IT network room/server closet is Access to the IT network room/server closet\n locked. at the Cut Bank and Miles City CBOCs was\n not documented.\n X All computer screens are locked when All computer screens at the Miles City\n not in use. CBOC were not locked when not in use.\n Staff use privacy screens on monitors to\n prevent unauthorized viewing in high-\n traffic areas.\n EOC rounds are conducted semi-\n annually (at least twice in a 12-month\n period).\n\n\n\nVA OIG Office of Healthcare Inspections 4\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n NM Areas Reviewed Findings\n X The CBOC has an AED. The Miles City CBOC did not have an AED.\n We found a code cart which is not in\n compliance with local emergency policy.\n Safety inspections are performed on\n CBOC medical equipment in accordance\n with VA and Joint Commission standards.\n X The parent facility includes the CBOC in The parent facility did not document EMP-\n required education, training, planning, specific training for Cut Bank and Miles City\n and participation leading up to the annual CBOCs\xe2\x80\x99 clinical providers.\n disaster exercise.\n X The parent facility\xe2\x80\x99s Emergency The parent facility\xe2\x80\x99s EMC did not evaluate\n Management Committee evaluates the Cut Bank and Miles City CBOCs\xe2\x80\x99\n CBOC emergency preparedness emergency preparedness activities,\n activities, participation in annual disaster participation in annual disaster exercise, and\n exercise, and staff training/education staff training/education relating to\n relating to emergency preparedness emergency preparedness requirements.\n requirements.\n\n1. We recommended that the side entrance door is ADA accessible at the Cut Bank CBOC.\n\n2. \t We recommended that the restroom is ADA accessible at the Cut Bank CBOC.\n\n3. \t We recommended that processes are improved to ensure review of the hazardous\n materials inventory occurs twice within a 12-month period for the Cut Bank and Miles City\n CBOCs.\n\n4. \t We recommended that signage is installed at the Cut Bank CBOC to clearly identify the\n location of fire extinguishers.\n\n5. \t We recommended that signage is installed at the Cut Bank CBOC to clearly identify exits.\n\n6. \t We recommended that the IT server closets at the Cut Bank and Miles City CBOCs are\n maintained according to IT safety and security standards.\n\n7. \t We recommended that computer screens are secured to eliminate viewing of PII by\n unauthorized individuals at the Miles City CBOC.\n\n8. \t We recommended that managers ensure that an AED is available at the Miles City CBOC.\n\n9. \t We recommended that the parent facility document EMP-specific training completed for the\n Cut Bank and Miles City CBOCs\xe2\x80\x99 clinical providers.\n\n10. \tWe recommended that the parent facility\xe2\x80\x99s EMC evaluate the Cut Bank and Miles City\n CBOCs\xe2\x80\x99 emergency preparedness activities, participation in annual disaster exercises, and\n staff training/education relating to emergency preparedness requirements.\n\n\n\n\nVA OIG Office of Healthcare Inspections 5\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nAUD\nThe purpose of this review was to determine whether the facility\xe2\x80\x99s CBOCs and PCCs complied\nwith selected alcohol use screening and treatment requirements.2\n\nWe reviewed relevant documents. We also reviewed 35 EHRs and validated findings with key\nmanagers and staff. The table below shows the areas reviewed for this topic. The areas\nmarked as NM did not meet applicable requirements and needed improvement.\n\nTable 3. AUD\n\n NM Areas Reviewed Findings\n Alcohol use screenings are completed\n during new patient encounters, and at\n least annually.\n X Diagnostic assessments are completed Staff did not complete diagnostic\n for patients with a positive alcohol screen. assessments for 11 (31 percent) of 35\n patients who had positive alcohol use\n screens.\n X Education and counseling about drinking Staff did not provide education and\n levels and adverse consequences of counseling for 2 of 18 patients who had\n heavy drinking are provided for patients positive alcohol use screens and drinking\n with positive alcohol screens and drinking levels above NIAAA guidelines.\n levels above NIAAA guidelines.\n X Documentation reflects the offer of further We did not find documentation of the offer of\n treatment for patients diagnosed with further treatment for 3 of 9 patients\n alcohol dependence. diagnosed with alcohol dependence.\n For patients with AUD who decline\n referral to specialty care, CBOC/PCC\n staff monitored them and their alcohol\n use.\n Counseling, education, and brief\n treatments for AUD are provided within 2\n weeks of positive screening.\n X CBOC/PCC RN Care Managers have We found that 5 of 27 RN Care Managers\n received MI training within 12 months of did not receive MI training within 12 months\n appointment to PACT. of appointment to PACT.\n CBOC/PCC RN Care Managers have\n received National Center for Health\n Promotion and Disease Prevention\n approved health coaching training (most\n likely TEACH for Success) within 12\n months of appointment to PACT.\n The facility complied with any additional\n elements required by VHA or local policy.\n\n\n\n\nVA OIG Office of Healthcare Inspections 6\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n11.\t We recommended that CBOC/PCC staff consistently complete follow-up assessments for\n patients with a positive alcohol screen.\n\n12.\t We recommended that CBOC/PCC staff provide education and counseling for patients with\n a positive alcohol screen and drinking levels above NIAAA limits.\n\n13. We recommended that CBOC/PCC staff consistently document the offer of further\n treatment to patients diagnosed with alcohol dependence.\n\n14.\t We recommended that CBOC/PCC RN Care Managers receive MI training within\n 12 months of appointment to PACT.\n\n\n\n\nVA OIG Office of Healthcare Inspections 7\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nMM\nThe purpose of this review was to determine whether appropriate clinical oversight and\neducation were provided to outpatients prescribed oral fluoroquinolone antibiotics.3\n\nWe reviewed relevant documents. We also reviewed 38 EHRs and validated findings with key\nmanagers and staff. The table below shows the areas reviewed for this topic. The areas\nmarked as NM did not meet applicable requirements and needed improvement.\n\nTable 4. Fluoroquinolones\n\n NM Areas Reviewed Findings\n X Clinicians documented the medication We did not find documentation that\n reconciliation process that included the medication reconciliation included the newly\n fluoroquinolone. prescribed fluroquinolone in 25 (66 percent)\n of 38 patients\xe2\x80\x99 EHRs.\n Written information on the patient\xe2\x80\x99s\n prescribed medications was provided at\n the end of the outpatient encounter.\n X Medication counseling/education for the We did not find documentation of medication\n fluoroquinolone was documented in the counseling that included the fluoroquinolone\n patients\xe2\x80\x99 EHRs. in 33 (87 percent) of 38 patients\xe2\x80\x99 EHRs.\n X Clinicians documented the evaluation of Clinicians did not document the level of\n each patient\xe2\x80\x99s level of understanding for understanding for 3 of 5 patients.\n the education provided.\n The facility complied with local policy.\n\n15. We recommended that CBOC/PCC staff document medication reconciliation that includes\n the newly prescribed fluoroquinolones in the EHR.\n\n16. We r\t ecommended that CBOC/PCC staff provide and document medication\n counseling/education that includes the fluoroquinolone.\n\n17. We recommended that CBOC/PCC staff document the evaluation of patient\xe2\x80\x99s level of\n understanding for the medication education.\n\n\n\n\nVA OIG Office of Healthcare Inspections 8\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nDWHP Proficiency\nThe purpose of this review was to determine whether the facility\xe2\x80\x99s CBOCs and PCC complied\nwith selected DWHP proficiency requirements.4\n\nWe reviewed the facility self-assessment, VHA and local policies, primary care management\nmodule data, and supporting documentation for DWHPs\xe2\x80\x99 proficiencies. The table below shows\nthe areas reviewed for this topic; NM denotes criterion \xe2\x80\x9cnot met.\xe2\x80\x9d The facility generally met\nrequirements. We made no recommendations.\n\nTable 5. DWHP Proficiency\n\n NM Areas Reviewed Findings\n CBOC and PCC DWHPs maintained\n proficiency requirements.\n CBOC and PCC DWHPs were\n designated with the WH indicator in the\n Primary Care Management Model.\n\n\n\n\nVA OIG Office of Healthcare Inspections 9\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix A\n\n\n CBOC Profiles \n\nThis review evaluates the quality of care provided to veterans at all of the CBOCs under the parent facility\xe2\x80\x99s oversight.c\nThe table below provides information relative to each of the CBOCs.\n\n Uniquesd Encountersd\n\n Station CBOC\n Location State Localitye MHg PCh Otheri All MHg PCh Otheri All\n # Sizef\n Billings MT 436GH Urban Large 1,491 5,706 8,773 9,530 9,926 18,111 53,387 81,424\n Missoula MT 436GC Urban Large 1,066 5,342 4,812 6,514 6,396 16,340 22,603 45,339\n Kalispell MT 436GF Rural Mid-Size 1,149 4,270 3,275 4,926 7,019 13,774 12,308 33,101\n Great Falls MT 436GB Urban Mid-Size 833 3,696 2,716 4,269 4,892 10,993 6,670 22,555\n Bozeman MT 436GD Rural Mid-Size 474 2,056 1,876 3,027 1,844 5,135 4,290 11,269\n Miles City MT 436GJ Highly Rural Mid-Size 339 1,114 1,060 1,767 999 3,080 4,903 8,982\n Anaconda MT 436GA Rural Small 395 1,066 771 1,461 1,559 2,994 3,494 8,047\n Glendive MT 436GK Highly Rural Small 307 507 370 809 747 1,495 700 2,942\n Lewistown MT 436GM Highly Rural Small 50 538 386 578 111 2,232 1,173 3,516\n Cut Bank MT 436GL Highly Rural Small 46 447 294 469 141 1,650 763 2,554\n Glasgow MT 436GI Highly Rural Small 35 415 246 457 111 1,390 432 1,933\n\n\n\n\nc\n Includes all CBOCs in operation before March 31, 2013. \n\nd\n Unique patients and Total Encounters \xe2\x80\x93 Source: MedSAS outpatient files; completed outpatient appointments indicated by a valid stop code during the \n\nJuly 1, 2012, through June 30, 2013, timeframe at the specified CBOC. \n\ne\n http://vaww.pssg.med.va.gov/PSSG/DVDC/FY2013_Q1_VAST.xlsx\n\nf\n Based on the number of unique patients seen as defined by VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, \n\nSeptember 11, 2008, the size of the CBOC facility is categorized as very large (> 10,000), large (5,000-10,000), mid-size (1,500-5,000), or small (< 1,500).\n\ng\n Mental Health includes stop codes in the 500 series, excluding 531 and 563, in the primary position. \n\nh\n Primary Care includes the stop code list in the primary position: 323 \xe2\x80\x93 Primary Care; 322 \xe2\x80\x93 Women\xe2\x80\x99s Clinic; 348 \xe2\x80\x93 Primary Care Group; 350 \xe2\x80\x93 Geriatric \n\nPrimary Care; 531 \xe2\x80\x93 MH Primary Care Team-Individual; 563 \xe2\x80\x93 MH Primary care Team-Group; 170 \xe2\x80\x93 Home Based Primary Care (HBPC) Physician. \n\ni\n All other non-Primary Care and non-MH stop codes in the primary position.\n\n\n\nVA OIG Office of Healthcare Inspections 10\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n CBOC Services Provided \n\nIn addition to primary care integrated with WH and MH care, the CBOCs provide various\nspecialty care, ancillary, and tele-health services. The following table lists the services\nprovided at each CBOC.j\n\n Tele-Health\n CBOC Specialty\xc2\xa0Care\xc2\xa0Servicesk Ancillary\xc2\xa0Servicesl\n Servicesm\n Billings Orthopedics Laboratory Tele Primary Care\n Cardiology Radiology\n Neurology Electrocardiography\n Gastroenterology Computer Tomography\n Urology MOVE! Programn\n Medicine Specialties Sleep Medicine\n Nutrition\n Diabetic Retinal Screening\n Pharmacy\n Pulmonary Function Test\n Echocardiography\n Missoula Orthopedics Rehabilitation Tele Primary Care\n Ophthalmology MOVE! Program\n Pharmacy\n Electrocardiography\n Diabetic Retinal Screening\n Sleep Medicine\n Diabetes Care\n Kalispell Orthopedics MOVE! Program Tele Primary Care\n Ear, Nose and Throat Electrocardiography\n Diabetic Retinal Screening\n Sleep Medicine\n Great Falls --- MOVE! Program Tele Primary Care\n Electrocardiography\n Diabetic Retinal Screening\n Sleep Medicine\n Pulmonary Function Test\n Bozeman Ophthalmology MOVE! Program Tele Primary Care\n Electrocardiography\n Diabetic Retinal Screening\n Miles City --- Rehabilitation Tele Primary Care\n MOVE! Program\n Electrocardiography\n Pharmacy\n Teleretinal\n Anaconda --- MOVE! Program Tele Primary Care\n Electrocardiography\n Diabetic Retinal Screening\n Health Screening\n\nj\n Source: MedSAS outpatient files; the denoted Specialty Care and Ancillary Services are limited to Primary Clinic \n\nStops with a count \xe2\x89\xa5 100 encounters during the July 1, 2012, through June 30, 2013, timeframe at the specified \n\nCBOC.\n\nk\n Specialty Care Services refer to non-Primary Care and non-MH services provided by a physician.\n\nl\n Ancillary Services refer to non-Primary Care and non-MH services that are not provided by a physician. \n\nm\n Tele-Health Services refer to services provided under the VA Telehealth program (http://www.telehealth.va.gov/) \n\nn\n VHA Handbook 1120.01, MOVE! Weight Management Program for Veterans, March 31, 2011. \n\n\nVA OIG Office of Healthcare Inspections 11\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n Glendive Montana --- MOVE! Program Tele Primary Care\n Electrocardiography\n Health Screening\n Teleretinal\n Lewistown --- MOVE! Program Tele Primary Care\n Electrocardiography\n Health Screening\n Teleretinal\n Cut Bank --- MOVE! Program Tele Primary Care\n Electrocardiography\n Health Screening\n Teleretinal\n Glasgow --- MOVE! Program Tele Primary Care\n Electrocardiography\n Health Screening\n Teleretinal\n\n\n\n\nVA OIG Office of Healthcare Inspections 12\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix B\n\n PACT Compass Metrics\n FY\xc2\xa02013\xc2\xa0Average\xc2\xa03rd\xc2\xa0Next\xc2\xa0Available\xc2\xa0in\xc2\xa0PC\xc2\xa0Clinics\n 50.0\n 45.0\n Average\xc2\xa0Number\xc2\xa0of\xc2\xa0Days\n\n\n\n\n 40.0\n 35.0\n 30.0\n 25.0\n 20.0\n 15.0\n 10.0\n 5.0\n 0.0\n Montana Anaconda Great\xc2\xa0Falls Missoula Bozeman Kalispell Billings Glasgow Miles\xc2\xa0City Glendive Cut\xc2\xa0Bank Lewistown\n VHA\xc2\xa0Total\n HCS\xc2\xa0(436) (436GA) (436GB) (436GC) (436GD) (436GF) (436GH) (436GI) (436GJ) (436GK) (436GL) (436GM)\n OCT\xc2\xa0FY13 14.6 13.8 0.5 2.0 2.6 2.0 6.8 15.5 7.2 5.5 2.2 0.9 3.2\n NOV\xc2\xa0FY13 15.2 7.3 1.4 11.4 3.6 4.8 7.0 14.5 44.9 2.9 4.1 2.8 2.8\n DEC\xc2\xa0FY13 13.8 6.4 1.3 2.3 5.0 3.8 10.1 13.1 0.0 3.8 3.2 2.3 2.2\n JAN\xc2\xa0FY13 14.0 5.8 3.8 3.1 3.8 4.1 7.1 11.2 1.1 16.5 11.6 3.9 2.6\n FEB\xc2\xa0FY13 14.8 10.8 10.8 3.9 5.6 3.7 8.3 11.5 1.6 10.6 25.8 3.6 2.5\n MAR\xc2\xa0FY13 13.3 8.3 8.8 4.5 7.0 2.7 4.6 10.0 1.2 9.0 10.0 2.0 1.2\n APR\xc2\xa0FY13 14.4 11.0 9.4 6.5 5.8 7.8 6.1 8.2 3.1 8.1 23.3 2.0 1.2\n MAY\xc2\xa0FY13 16.0 15.4 8.5 11.0 9.8 15.0 6.8 8.6 5.9 9.6 23.3 5.8 6.1\n JUN\xc2\xa0FY13 14.2 21.5 8.2 19.5 14.6 20.4 6.4 13.4 12.3 9.5 13.1 3.7 4.4\n JUL\xc2\xa0FY13 14.6 19.4 13.4 23.7 12.1 26.9 12.8 14.4 7.3 4.0 11.0 2.3 4.3\n AUG\xc2\xa0FY13 15.7 20.0 14.3 15.4 7.3 5.2 9.5 15.9 5.0 7.1 23.2 3.1 18.2\n SEP\xc2\xa0FY13 13.4 10.5 4.1 5.9 4.8 7.9 9.2 13.5 4.3 5.4 14.1 1.9 3.1\n\n\n\n\nData Definition.5 The average waiting time in days until the next third open appointment slot for completed primary care appointments in stop code 350.\n350. Completed appointments in stop code 350 for this metric include completed appointments where a 350 stop code is in the primary position on the\nappointment or one of the telephone stop codes is in the primary position, and 350 stop code is in the secondary position. The data is averaged from the\nnational to the division level.\n\nVA OIG Office of Healthcare Inspections 13\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n FY\xc2\xa02013\xc2\xa0Established\xc2\xa0PC\xc2\xa0Prospective\xc2\xa0Wait\xc2\xa0Times\xc2\xa07\xc2\xa0Days\n Percentage\xc2\xa0of\xc2\xa0Patients\xc2\xa0Scheduled\xc2\xa0 100%\n Within\xc2\xa07\xc2\xa0Days\xc2\xa0of\xc2\xa0Desired\xc2\xa0Date\n\n\n 80%\n\n\n\n\n 60%\n\n\n\n\n 40%\n\n\n\n\n 20%\n\n\n\n\n 0%\n Montana Anaconda Great\xc2\xa0Falls Missoula Bozeman Kalispell Billings Glasgow Miles\xc2\xa0City Glendive Cut\xc2\xa0Bank Lewistown\n VHA\xc2\xa0Total\n HCS\xc2\xa0(436) (436GA) (436GB) (436GC) (436GD) (436GF) (436GH) (436GI) (436GJ) (436GK) (436GL) (436GM)\n OCT\xc2\xa0FY13 83% 37.5% 100.0% 91.7% 58.6% 54.0% 87.6% 64.8% 68.0% 82.1% 100.0% 86.6% 76.6%\n NOV\xc2\xa0FY13 81.1% 26.0% 100.0% 95.8% 58.0% 58.9% 75.9% 60.0% 88.2% 75.7% 100.0% 81.1% 73.4%\n DEC\xc2\xa0FY13 82.4% 42.7% 100.0% 96.4% 58.4% 68.1% 78.7% 64.2% 94.7% 73.3% 100.0% 80.3% 73.8%\n JAN\xc2\xa0FY13 82.6% 45.0% 100.0% 100.0% 59.2% 52.9% 78.0% 69.2% 83.8% 69.4% 30.2% 79.7% 92.6%\n FEB\xc2\xa0FY13 83.2% 36.1% 95.7% 96.3% 67.4% 63.9% 82.1% 81.7% 91.7% 82.9% 39.3% 74.7% 83.7%\n MAR\xc2\xa0FY13 83.6% 48.8% 82.8% 92.3% 71.6% 64.0% 83.6% 81.1% 93.2% 75.4% 47.0% 80.3% 73.0%\n APR\xc2\xa0FY13 84.0% 38.9% 83.8% 96.4% 76.7% 66.5% 81.3% 80.6% 95.7% 68.7% 48.8% 79.4% 62.0%\n MAY\xc2\xa0FY13 84.0% 29.0% 84.5% 92.0% 71.5% 53.5% 81.4% 81.5% 97.6% 65.5% 39.0% 63.3% 73.6%\n JUN\xc2\xa0FY13 84.1% 51.6% 85.7% 92.7% 73.6% 54.9% 84.3% 88.9% 96.5% 84.3% 59.1% 71.2% 82.4%\n JUL\xc2\xa0FY13 84.3% 65.1% 91.9% 89.8% 80.3% 67.7% 88.9% 92.5% 85.4% 95.2% 68.1% 85.2% 94.0%\n AUG\xc2\xa0FY13 84.5% 64.9% 90.5% 90.5% 80.3% 70.5% 91.0% 91.2% 87.0% 97.4% 67.9% 87.9% 89.5%\n SEP\xc2\xa0FY13 84.7% 66.6% 78.7% 89.1% 82.7% 75.4% 86.8% 90.8% 90.4% 97.9% 68.0% 90.0% 90.4%\n\n\n\nData Definition.5 The percent of patients scheduled within 7 days of the desired date. Data source is the Wait Times Prospective Wait Times measures. The\ntotal number of scheduled appointments for primary care-assigned patients in primary care clinics 322, 323 and 350. Data is collected twice a month on the\n1st and the 15th. Data reported is for the data pulled on the 15th of the month. There is no FY to date score for this measure.\n\nVA OIG Office of Healthcare Inspections 14\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n FY\xc2\xa02013\xc2\xa0Ratio\xc2\xa0of\xc2\xa0ER\xc2\xa0Encounters\xc2\xa0While\xc2\xa0on\xc2\xa0Panel\xc2\xa0to\n PC\xc2\xa0Encounters\xc2\xa0While\xc2\xa0on\xc2\xa0Panel\xc2\xa0(FEE\xc2\xa0ER\xc2\xa0Included)\n 38%\n 36%\n 34%\n 32%\n Percentage\xc2\xa0of\xc2\xa0ER\xc2\xa0Encounters\xc2\xa0\n\n 30%\n 28%\n 26%\n 24%\n to\xc2\xa0PC\xc2\xa0Encounters\n\n\n\n 22%\n 20%\n 18%\n 16%\n 14%\n 12%\n 10%\n 8%\n 6%\n 4%\n 2%\n 0%\n OCT\xc2\xa0FY13 NOV\xc2\xa0FY13 DEC\xc2\xa0FY13 JAN\xc2\xa0FY13 FEB\xc2\xa0FY13 MAR\xc2\xa0FY13 APR\xc2\xa0FY13 MAY\xc2\xa0FY13 JUN\xc2\xa0FY13 JUL\xc2\xa0FY13 AUG\xc2\xa0FY13 SEP\xc2\xa0FY13\n VHA\xc2\xa0Total 16.3% 16.3% 16.4% 16.3% 16.3% 16.3% 16.1% 16.1% 16.0% 15.9% 15.8% 15.7%\n \xc2\xa0Montana\xc2\xa0HCS\xc2\xa0(436) 36.5% 36.0% 35.6% 35.5% 35.0% 34.3% 33.7% 32.7% 31.1% 30.9% 30.7% 30.6%\n Anaconda\xc2\xa0(436GA) 12.6% 12.9% 12.7% 12.7% 12.5% 12.5% 12.8% 13.8% 13.2% 13.1% 13.7% 13.4%\n Great\xc2\xa0Falls\xc2\xa0(436GB) 8.6% 8.4% 8.6% 8.2% 8.1% 7.6% 7.8% 7.9% 7.5% 7.0% 7.1% 6.3%\n Missoula\xc2\xa0(436GC) 8.7% 8.8% 8.7% 8.8% 8.8% 8.4% 8.3% 8.1% 7.9% 7.4% 6.8% 6.2%\n Bozeman\xc2\xa0(436GD) 10.4% 10.0% 9.7% 9.6% 6.9% 7.2% 8.0% 8.5% 8.9% 8.7% 8.7% 8.5%\n Kalispell\xc2\xa0(436GF) 6.3% 6.1% 6.0% 5.8% 5.5% 5.5% 5.5% 5.2% 5.2% 4.8% 4.5% 4.2%\n Billings\xc2\xa0(436GH) 3.5% 3.5% 3.3% 3.2% 3.2% 3.1% 3.0% 2.9% 2.9% 2.7% 2.4% 2.3%\n Glasgow\xc2\xa0(436GI) 7.5% 5.8% 5.1% 8.3% 5.1% 4.1% 4.4% 3.9% 2.8% 0.8% 0.5% 0.8%\n Miles\xc2\xa0City\xc2\xa0(436GJ) 3.7% 4.1% 3.8% 3.4% 3.8% 3.8% 3.6% 3.7% 3.7% 3.5% 3.1% 2.8%\n Glendive\xc2\xa0(436GK) 1.8% 1.8% 2.0% 3.8% 4.2% 3.3% 3.0% 2.6% 2.0% 2.3% 2.3% 1.8%\n Cut\xc2\xa0Bank\xc2\xa0(436GL) 8.1% 7.0% 6.9% 6.6% 6.3% 6.4% 5.0% 4.1% 4.2% 4.2% 3.8% 3.5%\n Lewistown\xc2\xa0(436GM) 7.6% 7.6% 7.2% 7.2% 7.4% 6.5% 6.0% 5.7% 5.5% 4.5% 3.5% 2.3%\n\n\n\n\nData Definition.5 This is a measure of where the patient receives his or her primary care and by whom. A low percentage is better. The formula is the total\nVHA ER/Urgent Care/FEE ER Encounters WOP (including FEE ER visits) divided by the number of primary care encounters WOP with the patient\xe2\x80\x99s\nassigned primary care (or associate) provider plus the total VHA ER/Urgent Care/FEE ER Encounters (including FEE ER visits) WOP plus the number of\nprimary care encounters WOP with a provider other than the patient\xe2\x80\x99s PCP/AP.\nVA OIG Office of Healthcare Inspections 15\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n\n FY\xc2\xa02013\xc2\xa02\xe2\x80\x90Day\xc2\xa0Contact\xc2\xa0Post\xc2\xa0Discharge\xc2\xa0Ratio\n 100%\n 90%\n 80%\n 70%\n 60%\n 50%\n 40%\n 30%\n 20%\n 10%\n 0%\n Montana Anaconda Great\xc2\xa0Falls Missoula Bozeman Kalispell Billings Glasgow Miles\xc2\xa0City Glendive Cut\xc2\xa0Bank Lewistown\n VHA\xc2\xa0Total\n HCS\xc2\xa0(436) (436GA) (436GB) (436GC) (436GD) (436GF) (436GH) (436GI) (436GJ) (436GK) (436GL) (436GM)\n OCT\xc2\xa0FY13 52.8% 53.2% 50.0% 54.5% 51.2% 43.8% 50.0% 30.3% 0.0% 16.7% 50.0% 0.0% 40.0%\n NOV\xc2\xa0FY13 52.9% 59.0% 100.0% 56.5% 37.9% 12.5% 39.1% 20.0% 33.3% 14.3% 100.0% 33.3% 0.0%\n DEC\xc2\xa0FY13 51.5% 51.9% 33.3% 26.9% 37.8% 26.7% 27.3% 41.4% 0.0% 33.3% 50.0% 66.7% 50.0%\n JAN\xc2\xa0FY13 57.2% 55.6% 66.7% 31.6% 40.6% 54.5% 23.5% 21.2% 0.0% 33.3% 0.0% 75.0%\n FEB\xc2\xa0FY13 60.4% 51.2% 100.0% 57.1% 28.1% 18.8% 38.5% 39.3% 0.0% 25.0% 0.0% 100.0% 100.0%\n MAR\xc2\xa0FY13 64.4% 57.1% 87.5% 11.1% 31.7% 15.4% 60.9% 54.1% 20.0% 0.0% 60.0%\n APR\xc2\xa0FY13 65.5% 65.1% 66.7% 53.3% 40.0% 25.0% 38.9% 63.3% 50.0% 60.0% 33.3% 50.0% 25.0%\n MAY\xc2\xa0FY13 66.1% 70.7% 60.0% 55.6% 35.5% 54.5% 38.9% 57.1% 50.0% 33.3% 100.0% 100.0% 0.0%\n JUN\xc2\xa0FY13 70.1% 77.3% 100.0% 50.0% 36.4% 25.0% 42.9% 57.9% 100.0% 0.0% 0.0% 33.3%\n JUL\xc2\xa0FY13 71.1% 81.4% 100.0% 50.0% 25.0% 33.3% 33.3% 71.4% 0.0% 0.0%\n AUG\xc2\xa0FY13 72.7% 82.4% 100.0% 63.2% 47.4% 20.0% 70.0% 68.8% 50.0% 80.0% 100.0%\n SEP\xc2\xa0FY13 68.9% 65.8% 40.0% 77.8% 48.3% 63.6% 52.9% 84.6% 100.0% 0.0% 0.0% 100.0%\n\n\n\n\nData Definition.5 Total Discharges Included in 2-day Contact Post Discharge Ratio: The total VHA and FEE Inpatient Discharges for assigned primary care\npatients for the reporting timeframe. Discharges resulting in death and discharges where a patient is readmitted within 2 days of discharge are excluded from\nthis metric. Blank cells indicate the absence of reported data.\n\n\nVA OIG Office of Healthcare Inspections 16\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix C\n VISN Director Comments\n\n\n Department of\n Veterans Affairs Memorandum\n\n\n Date: January 13, 2014\n\n From: Director, VISN 19 (10N19)\n\n Subject: CBOC and PCC Reviews of the VA Montana Health Care\n System, Fort Harrison, MT\n\n To: Director, Seattle Office of Healthcare Inspections (54SE)\n\n Director, Management Review Service (VHA 10AR MRS\n OIG CAP CBOC)\n\n I have reviewed and concurred on the response from VA Montana Health\n Care System. If you have any further questions, please contact Ms.\n Susan Curtis, VISN 19 HSS at (303) 639-6995.\n\n\n\n\nVA OIG Office of Healthcare Inspections 17\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix D\n Facility Director Comments\n\n\n\n Department of\n Veterans Affairs Memorandum\n\n\n Date: January 13, 2014\n\n From: Director, VA Montana Health Care System (436/00)\n\n Subject: CBOC and PCC Reviews of the VA Montana Health Care\n System, Fort Harrison, MT\n\n To: Director, Rocky Mountain Health Care Network (VISN19)\n\n 1. The VA Montana Health Care System has reviewed and concurs\n with the findings included in the draft Community Based Outpatient\n Clinic and Primary Care Clinic Report. A response is provided\n along with target dates of completion for each recommendation.\n\n 2. If you have questions or need additional information, please contact\n Vicki Thennis Chief Quality Management Officer at 406-447-7863\n or vicki.thennis@va.gov.\n\n\n\n\n (original signed by:)\n\n Christine Gregory, FACHE\n\n Director, VA Montana Health Care System (436/00)\n\n\n\n\nVA OIG Office of Healthcare Inspections 18\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\n Comments to OIG\xe2\x80\x99s Report\n\nThe following Director\xe2\x80\x99s comments are submitted in response to the recommendations\nin the OIG report:\n\nOIG Recommendations\n\nRecommendation 1. We recommended that the side entrance door is ADA accessible\n\nat the Cut Bank CBOC. \n\n\nConcur\n\n\nTarget date for completion: 4/1/2014 \n\n\nFacility response: VA Montana Health Care System (VAMTHCS) will ensure ADA \n\ncompliant automatic door opener is properly functioning. We will also ensure door\n\nhardware is ADA compliant. \n\n\nRecommendation 2. We recommended that the restroom is ADA accessible at the Cut \n\nBank CBOC. \n\n\nConcur\n\n\nTarget date for completion: 4/1/2014 \n\n\nFacility response: VAMTHCS will ensure door hardware is ADA compliant. \n\n\nRecommendation 3. We recommended that processes are improved to ensure review \n\nof the hazardous materials inventory occurs twice within a 12-month period for the Cut \n\nBank and Miles City CBOCs. \n\n\nConcur\n\n\nTarget date for completion: 9/30/2014 \n\n\nFacility response: VAMTHCS will develop and implement a program ensuring a review \n\nof the hazardous materials inventory occurs twice within a 12 month period. \n\n\nRecommendation 4. We recommended that signage is installed at the Cut Bank\n\nCBOC to clearly identify the location of fire extinguishers. \n\n\nConcur \n\n\nTarget date for completion: 4/1/2014 \n\n\nFacility response: The fire extinguisher in question will be moved to the lobby and a sign \n\nwill be posted indicating fire extinguisher. \n\n\n\n\nVA OIG Office of Healthcare Inspections 19\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nRecommendation 5. We recommended that signage is installed at the Cut Bank\nCBOC to clearly identify exits.\n\nConcur\n\nTarget date for completion: 6/1/2014\n\nFacility response: VAMTHCS will install \xe2\x80\x9cNot an Exit\xe2\x80\x9d sign on the door that leads to the\noutside of the clinic through the back. Staff at the Cut Bank CBOC will be educated and\ntrained that this door is not an exit and in case of emergency patients and staff are to\nexit from the building through the front exit door.\n\nRecommendation 6. We recommended that the IT server closets at the Cut Bank and\nMiles City CBOCs are maintained according to IT safety and security standards.\n\nConcur\n\nTarget date for completion: Completed\n\nFacility response: Access logs have been placed in the IT closets at the Cut Bank and\nMiles City CBOCs. Local staff have been given instruction related to VA Handbook\n6500, Appendix D in regards to the requirement for visitors to log in when visiting the IT\nspaces.\n\nRecommendation 7. We recommended that computer screens are secured to\neliminate viewing of PII by unauthorized individuals at the Miles City CBOC.\n\nConcur\n\nTarget date for completion: 9/30/2014\n\nFacility response: The Privacy Officer participated in EOC rounds to the Cut Bank\nCBOC on November 13, 2013 and the Miles City CBOC on December 12, 2013. Staff\nat both CBOCs were provided instruction on the need for keeping computer screens\nsecured to eliminate viewing of PII by unauthorized individuals. Monitoring of this\nactivity will occur during the monthly CBOC inspections by CBOC leaders for the next 4\nmonths and during scheduled team EOC rounds by the Privacy Officer (or designees)\nduring the remainder of FY 2014.\n\nRecommendation 8. We recommended that managers ensure that an AED is\navailable at the Miles City CBOC.\n\nConcur\n\nTarget date for completion: 6/1/2014\n\n\n\n\nVA OIG Office of Healthcare Inspections 20\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nFacility response: An order for an AED has been placed and it will be put into service in\nthe Miles City CBOC upon arrival. The Nurse Manager has been designated the point\nof contact for ensuring placement, training and monitoring of this device.\n\nRecommendation 9. We recommended that the parent facility document EMP-specific\ntraining completed for the Cut Bank and Miles City CBOCs\xe2\x80\x99 clinical providers.\n\nConcur\n\nTarget date for completion: 6/1/2014\n\nFacility response: The Emergency Preparedness Coordinator will ensure clinical\nproviders at VAMTHCS CBOCs complete the required Emergency Management\ntraining module(s) and will include documentation of that training in the Emergency\nManagement Committee minutes at least annually.\n\nRecommendation 10. We recommended that the parent facility\xe2\x80\x99s EMC evaluate the\nCut Bank and Miles City CBOCs\xe2\x80\x99 emergency preparedness activities, participation in\nannual disaster exercises, and staff training/education relating to emergency\npreparedness requirements.\n\nConcur\n\nTarget date for completion: 6/1/2014\n\nFacility response: The Emergency Preparedness Coordinator will ensure disaster\nexercise plans, scenarios, and critiques are included in the regular Emergency\nManagement Committee minutes. Committee members will be asked to review and\napprove of these elements and to help ensure staff training and education, in order to\nfully comply with this recommendation.\n\nRecommendation 11. We recommended that CBOC/PCC staff consistently complete\nfollow-up assessments for patients with a positive alcohol screen.\n\nConcur\n\nTarget date for completion: 7/1/2014\n\nFacility response: The National Clinical reminder for alcohol use was reviewed and is in\nplace in the electronic medical record for use. The Associate Chief of Staff Ambulatory\nCare will provide instruction to all CBOC providers to consistently complete follow-up\nassessments for patients with a positive alcohol screen utilizing the entire national\nclinical reminder for follow-up to a positive AUDIT C screen. The nurse managers for\nAmbulatory Care will conduct an audit of patient records with a positive AUDIT C screen\nfor 90 days to monitor compliance.\n\n\n\n\nVA OIG Office of Healthcare Inspections 21\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nRecommendation 12. We recommended that CBOC/PCC staff provide education and\ncounseling for patients with positive alcohol screen and drinking levels above NIAAA\nlimits.\n\nConcur\n\nTarget date for completion: 7/1/2014\n\nFacility response: The facility CAC will modify the dialog in the National Clinical\nreminder to prompt the clinical staff to provide education and counseling for patient with\npositive alcohol screens and drinking levels above NIAAA limits. A template is being\ndeveloped to assist in documentation of the education provided to the patient. The\nAssociate Chief of Staff for Ambulatory Care will provide instruction to all CBOC\nproviders to convey the education and counseling as appropriate for patients with\npositive alcohol screens and to document the counseling utilizing the template. The\nnurse managers for Ambulatory Care will conduct an audit of patient records with a\npositive AUDIT C screen for 90 days to monitor compliance.\n\nRecommendation 13. We recommended that CBOC/PCC staff consistently document\nthe offer of further treatment to patients diagnosed with alcohol dependence.\n\nConcur\n\nTarget date for completion: 7/1/2014\n\nFacility response: The facility CAC will modify the dialog in the National Clinical\nreminder to prompt the clinical staff to offer a referral for further treatment to patients\ndiagnosed with alcohol dependence. A template is being developed to assist in\ndocumentation of the referral offer and education provided to the patient. The Associate\nChief of Staff for Ambulatory Care will provide instruction to all CBOC providers to offer\na referral for further treatment and counseling as appropriate for patients diagnosed with\nalcohol dependence and to document utilizing the template. The nurse managers for\nAmbulatory Care will conduct an audit of patient records with a positive AUDIT C screen\nfor 90 days to monitor compliance.\n\nRecommendation 14. We recommended that CBOC/PCC RN Care Managers receive\nMI training within 12 months of appointment to PACT.\n\nConcur\n\nTarget date for completion: 4/1/2014\n\nFacility response: As of date there have been multiple training opportunities offered and\nthe Education Service has worked with managers to make sure targeted staff attend the\ntrainings. Those that were on the list of not receiving MI training have already\ncompleted or are on a schedule to complete the training. Going forward, the Education\nService will work with Ambulatory Care managers quarterly to identify staff needing the\nmandatory training and schedule it appropriately.\n\n\nVA OIG Office of Healthcare Inspections 22\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n\n\nRecommendation 15. We recommended that CBOC/PCC staff document medication\nreconciliation that includes the newly prescribed fluoroquinolones in the EHR.\n\nConcur\n\nTarget date for completion: 7/1/2014\n\nFacility response: The Pharmacy Service Chief will place fluoroquinolones in a special\nordering category that gives prompts for additional requirements, such as medication\nreconciliation, when ordering these medications. The Associate Chief of Staff for\nAmbulatory Care will provide instruction to all CBOC providers to complete medication\nreconciliation when ordering Fluoroquinolones and document it using the Med Rec\nOutpatient note. The Quality Department will audit a sampling of EHRs for 90 days to\nmonitor compliance and will report the results to the P&T committee.\n\nRecommendation 16. We recommended that CBOC/PCC staff provide and document\nmedication counseling/education that includes the fluoroquinolone.\n\nConcur\n\nTarget date for completion: 7/1/2014\n\nFacility response: The Associate Chief of Staff for Ambulatory Care will instruct\nproviders to include patient education specific to Fluoroquinolones when ordering the\nmedication and to document that education in the EHR. The medication reconciliation\ntemplate will include the education provided to the patient regarding Fluorquinolone use.\nThe Quality Department will audit a sampling of EHRs for 90 days to monitor\ncompliance and will report the results to the P&T committee.\n\nRecommendation 17. We recommended that CBOC/PCC staff document the\nevaluation of patient\xe2\x80\x99s level of understanding for the medication education.\n\nConcur\n\nTarget date for completion: 7/1/2014\n\nFacility response: The Associate Chief of Staff for Ambulatory Care will instruct\nproviders to include patient education specific to Fluoroquinolones when ordering the\nmedication and to document that education including the patient\xe2\x80\x99s response to the\neducation in the EHR. The medication reconciliation template will include the education\nprovided and the patient\xe2\x80\x99s response to the education regarding Fluoroquinolone use.\nThe Quality Department will audit a sampling of EHRs for 90 days to monitor\ncompliance and will report the results to the P&T committee.\n\n\n\n\nVA OIG Office of Healthcare Inspections 23\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix E\n\n OIG Contact and Staff Acknowledgments\nContact For more information about this report, please contact the OIG\n at (202) 461-4720.\nOnsite Mary Noel Rees, MPA, Team Leader\nContributors Sarah Lutter, RN, JD\nOther Lin Clegg, PhD\nContributors Matt Frazier, MPH\n Zhana Johnson, CPA\n Jeff Joppie, BS\n Marc Lainhart, BS\n Sami O\xe2\x80\x99Neill, MA\n Jennifer Reed, RN, MSHI\n Victor Rhee, MHS\n Patrick Smith, M. Stat\n Marilyn Stones, BS\n Mary Toy, RN, MSN\n Jarvis Yu, MS\n\n\n\n\nVA OIG Office of Healthcare Inspections 24\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix F\n\n\n Report Distribution\nVA Distribution\n\nOffice of the Secretary\nVeterans Health Administration\nAssistant Secretaries\nGeneral Counsel\nDirector, VISN 19 (10N19)\nDirector, VA Montana Health Care System (436/00)\n\nNon-VA Distribution\n\nHouse Committee on Veterans\xe2\x80\x99 Affairs\nHouse Appropriations Subcommittee on Military Construction, Veterans Affairs, and\n Related Agencies\nHouse Committee on Oversight and Government Reform\nSenate Committee on Veterans\xe2\x80\x99 Affairs\nSenate Appropriations Subcommittee on Military Construction, Veterans Affairs, and\n Related Agencies\nSenate Committee on Homeland Security and Governmental Affairs\nNational Veterans Service Organizations\nGovernment Accountability Office\nOffice of Management and Budget\nU.S. Senate: Max Baucus, John Tester\nU.S. House of Representatives: Steve Daines\n\n\nThis report is available at www.va.gov/oig.\n\n\n\n\nVA OIG Office of Healthcare Inspections 25\n\x0c CBOC and PCC Reviews at VA Montana Health Care System, Fort Harrison, MT\n Appendix G\n\n Endnotes \n\n\n1\n References used for the EOC review included:\n\xef\x82\xb7\t US Access Board, Americans with Disabilities Act Accessibility Guidelines (ADAAG), September 2, 2002.\n\xef\x82\xb7\t US Department of Health and Human Services, Health Insurance Portability and Accountability Act, The\n Privacy Rule, August 14, 2002.\n\xef\x82\xb7\t US Department of Labor, Occupational Safety and Health Administration, Laws and Regulations.\n\xef\x82\xb7\t US Department of Labor, Occupational Safety and Health Administration, Guidelines for Preventing Workplace\n Violence, 2004.\n\xef\x82\xb7\t Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2013.\n\xef\x82\xb7\t VA Directive 0324, Test, Training, Exercise, and Evaluation Program, April 5, 2012.\n\xef\x82\xb7\t VA Directive 0059, VA Chemicals Management and Pollution Prevention, May 25, 2012.\n\xef\x82\xb7\t VA Handbook 6500, Risk Management Framework for VA Information System, September 20, 2012.\n\xef\x82\xb7\t VHA Center for Engineering, Occupational Safety, and Health, Emergency Management Program Guidebook,\n March 2011.\n\xef\x82\xb7\t VHA Center for Engineering, Occupational Safety, and Health, Online National Fire Protection Association\n Codes, Standards, Handbooks, and Annotated Editions of Select Codes and Standards, July 9, 2013.\n\xef\x82\xb7\t VHA Deputy Under Secretary for Health for Operations and Management, Memorandum: Environmental\n Rounds, March 5, 2007.\n\xef\x82\xb7\t VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011.\n\xef\x82\xb7\t VHA Directive 2012-026, Sexual Assaults & Other Defined Public Safety Incidents in VHA Facilities,\n September 27, 2012.\n\xef\x82\xb7\t VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004.\n\xef\x82\xb7\t VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010.\n\xef\x82\xb7\t VHA Handbook 1850.05, Interior Design Operations and Signage, July 1, 2011.\n2\n References used for the AUD review included:\n\xef\x82\xb7\t National Center for Health Promotion and Disease Prevention (NCP) and Office of Veteran Health Education\n and Information (NVEI), Patient Education: TEACH for Success, 2010. Retrieved from\n http://www.prevention.va.gov/HealthPOWER_Prevention_News_Summer_2010_VHEI.asp on\n January 17, 2014.\n\xef\x82\xb7\t VHA Handbook 1120.02, Health Promotion Disease Prevention (HPDP) Program, July 5, 2012.\n\xef\x82\xb7\t VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics,\n September 11, 2008.\n3\n References used for the Medication Management review included:\n\xef\x82\xb7\t VHA Directive 2011-012, Medication Reconciliation, March 9, 2011.\n\xef\x82\xb7\t VHA Directive 2012-011, Primary Care Standards, April 11, 2012.\n\xef\x82\xb7\t VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006.\n\xef\x82\xb7\t VHA Handbook 1108.07, Pharmacy General Requirements, April 17, 2008.\n\xef\x82\xb7\t Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2013.\n4\n References used for the DWHP review included:\n\xef\x82\xb7\t VHA Deputy Under Secretary for Health for Operations and Management, Memorandum: Health Care Services\n for Women Veterans, Veterans Health Administration (VHA) Handbook 1330.01; Women\xe2\x80\x99s Health (WH)\n Primary Care Provider (PCP) Proficiency, July 8, 2013.\n\xef\x82\xb7\t VHA Handbook 1330.01 Health Care Services for Women Veterans, May 21, 2010.\n\xef\x82\xb7\t VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.\n5\n Reference used for PACT Compass data graphs:\n\xef\x82\xb7\t Department of Veterans\xe2\x80\x99 Affairs, Patient Aligned Care Teams Compass Data Definitions, August 29, 2013.\xc2\xa0\n\n\n\xc2\xa0\n\n\n\n\nVA OIG Office of Healthcare Inspections 26\n\x0c'


type: contracts

jurisdiction: EU

text:
 4.8.2016
 SL
 Uradni list Evropske unije
 L 211/55
 SKLEP SKUPNEGA ODBORA EGP
 št. 102/2015
 z dne 30. aprila 2015
 o spremembi Priloge X (Splošne storitve) in Protokola 31 (o sodelovanju na posebnih področjih, za katera ne veljajo štiri temeljne svobode) k Sporazumu EGP [2016/1285]
 SKUPNI ODBOR EGP JE –
 ob upoštevanju Sporazuma o Evropskem gospodarskem prostoru (v nadaljnjem besedilu: Sporazum EGP) ter zlasti členov 86 in 98 Sporazuma EGP,
 ob upoštevanju naslednjega:
 (1)
 Uredbo (EU) št. 1024/2012 Evropskega parlamenta in Sveta z dne 25. oktobra 2012 o upravnem sodelovanju prek informacijskega sistema za notranji trg in razveljavitvi Odločbe Komisije 2008/49/ES (1) je treba vključiti v Sporazum EGP.
 (2)
 Uredba (EU) št. 1024/2012 razveljavlja Odločbo Komisije 2008/49/ES (2), ki je vključena v Sporazum EGP, zato bi bilo treba sklic na Odločbo 2008/49/ES črtati iz Sporazuma EGP.
 (3)
 Prilogo X in Protokol 31 k Sporazumu EGP je zato treba ustrezno spremeniti –
 SPREJEL NASLEDNJI SKLEP:
 Člen 1
 Za točko 2d (Izvedbeni sklep Komisije 2014/287/EU) Priloge X k Sporazumu EGP se vstavi naslednje:
 „3.
 32012 R 1024: Uredba (EU) št. 1024/2012 Evropskega parlamenta in Sveta z dne 25. oktobra 2012 o upravnem sodelovanju prek informacijskega sistema za notranji trg in razveljavitvi Odločbe Komisije 2008/49/ES (UL L 316, 14.11.2012, str. 1).
 Za namene tega sporazuma se določbe Uredbe uporabljajo z naslednjimi prilagoditvami:
 (a)
 Besedili ‚člena 26(2) Pogodbe o delovanju Evropske unije (PDEU)‘ in ‚člena 26(2) PDEU‘ se nadomestita z besedilom ‚člena 1(2)(a) do (d) Sporazuma EGP‘.
 (b)
 Besedilo ‚akti Unije‘ v vseh sklonih se nadomesti z besedilom ‚akti Unije, ki so vključeni v Sporazum EGP‘ v ustreznem sklonu.“
 Člen 2
 Besedilo druge alinee (Odločba Komisije 2008/49/ES) člena 17(6)(b) Protokola 31 k Sporazumu EGP se črta.
 Člen 3
 Besedilo Uredbe (EU) št. 1024/2012 v islandskem in norveškem jeziku, ki se objavi v Dopolnilu EGP k Uradnemu listu Evropske unije, je verodostojno.
 Člen 4
 Ta sklep začne veljati 1. maja 2015 pod pogojem, da so bila predložena vsa uradna obvestila v skladu s členom 103(1) Sporazuma EGP (*).
 Člen 5
 Ta sklep se objavi v sklopu EGP Uradnega lista Evropske unije in v Dopolnilu EGP k Uradnemu listu Evropske unije.
 V Bruslju, 30. aprila 2015
 Za Skupni odbor EGP
 Predsednik
 Gianluca GRIPPA
 (1) UL L 316, 14.11.2012, str. 1.
 (2) UL L 13, 16.1.2008, str. 18.
 (*) Navedene so ustavne zahteve.


type: caselaw

text:
 13.4.2015
 LV
 Eiropas Savienības Oficiālais Vēstnesis
 C 118/40
 Prasība, kas celta 2015. gada 12. februārī – Tronios Group International/ITSB – British Sky Broadcasting Group (“SkyTec”)
 (Lieta T-77/15)
 (2015/C 118/51)
 Valoda, kādā sagatavots prasības pieteikums – holandiešu
 Lietas dalībnieki
 Prasītāja: Tronios Group International BV (Breda, Nīderlande) (pārstāvji – R. van Leeuwen un H. Klingenberg, advokāti)
 Atbildētājs: Iekšējā tirgus saskaņošanas birojs (preču zīmes, paraugi un modeļi) (ITSB)
 Otra procesa ITSB Apelāciju padomē dalībniece: British Sky Broadcasting Group plc (Isleworth, Apvienotā Karaliste)
 Informācija par procesu ITSB
 Strīdus preču zīmes īpašniece: Tronios Group International BV
 Attiecīgā strīdus preču zīme: Kopienas vārdiska preču zīme “SkyTec”
 Process ITSB: spēkā neesamības atzīšanas process
 Apstrīdētais lēmums: ITSB Apelāciju ceturtās padomes 2014. gada 28. novembra lēmums lietā R 1681/2013-4
 Prasītājas prasījumi:
 —
 atcelt apstrīdēto lēmumu un noraidīt British Sky Broadcasting Group spēkā neesamības atzīšanas pieteikumu;
 —
 piespriest British Sky Broadcasting Group atlīdzināt šajā tiesvedībā un iepriekšējā procesā ITSB radušos tiesāšanās izdevumus.
 Izvirzītie pamati:
 —
 Regulas Nr. 207/2009 54. panta 2. punkta pārkāpums;
 —
 Regulas Nr. 207/2009 8. panta 1. punkta b) apakšpunkta pārkāpums.


type: legislation

text:
 6.10.2020
 DA
 Den Europæiske Unions Tidende
 L 324/2
 KOMMISSIONENS GENNEMFØRELSESFORORDNING (EU) 2020/1394
 af 29. september 2020
 om registrering af en betegnelse i registret over beskyttede oprindelsesbetegnelser og beskyttede geografiske betegnelser (»Varaždinski klipič« (BGB))
 EUROPA-KOMMISSIONEN HAR —
 under henvisning til traktaten om Den Europæiske Unions funktionsmåde,
 under henvisning til Europa-Parlamentets og Rådets forordning (EU) nr. 1151/2012 af 21. november 2012 om kvalitetsordninger for landbrugsprodukter og fødevarer (1), særlig artikel 52, stk. 2, og
 ud fra følgende betragtninger:
 (1)
 Kroatiens ansøgning om registrering af betegnelsen »Varaždinski klipič« er blevet offentliggjort i Den Europæiske Unions Tidende (2), jf. artikel 50, stk. 2, litra a), i forordning (EU) nr. 1151/2012.
 (2)
 Da Kommissionen ikke har modtaget indsigelser, jf. artikel 51 i forordning (EU) nr. 1151/2012, skal betegnelsen »Varaždinski klipič« registreres —
 VEDTAGET DENNE FORORDNING:
 Artikel 1
 Betegnelsen »Varaždinski klipič« (BGB) registreres.
 Betegnelsen i stk. 1 henviser til et produkt i kategori 2.3 Brød, wienerbrød, kager, kiks og andet bagværk samt konfekturevarer i bilag XI til Kommissionens gennemførelsesforordning (EU) nr. 668/2014 (3).
 Artikel 2
 Denne forordning træder i kraft på tyvendedagen efter offentliggørelsen i Den Europæiske Unions Tidende.
 Denne forordning er bindende i alle enkeltheder og gælder umiddelbart i hver medlemsstat.
 Udfærdiget i Bruxelles, den 29. september 2020.
 På Kommissionens vegne
 For formanden
 Janusz WOJCIECHOWSKI
 Medlem af Kommissionen
 (1) EUT L 343 af 14.12.2012, s. 1.
 (2) EUT C 197 af 12.6.2020, s. 26.
 (3) Kommissionens gennemførelsesforordning (EU) nr. 668/2014 af 13. juni 2014 om fastlæggelse af regler for anvendelsen af Europa-Parlamentets og Rådets forordning (EU) nr. 1151/2012 om kvalitetsordninger for landbrugsprodukter og fødevarer (EUT L 179 af 19.6.2014, s. 36).