Report Summary

Title: Healthcare Inspection – Pharmacy and Quality of Care Issues, VA Hudson Valley Health Care System, Castle Point, New York
Report Number: 12-02352-72
Issue Date: 12/21/2012
City/State:
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The VA Office of Inspector General Office of Healthcare Inspections conducted a review to determine the validity of several allegations at the Castle Point Campus of the VA Hudson Valley Health Care System in Castle Point, NY. We did not substantiate that patients died in the chemotherapy clinic or during transfer to community hospitals; however, we found issues with chemotherapy treatment timeliness. We presented findings to the Director about deceptive pharmacy inventory management practices, which resulted in the appointment of an Administrative Investigation Board (AIB). We reviewed and concurred with the findings and recommendations of the AIB. We confirmed that supplies were moved to the basement to exclude them from the pharmacy inventory count but did not substantiate that they remained there and went unused. We determined that there were drug shortages caused by an inadequate inventory management system and national vendor back-orders. We did not substantiate allegations related to physician hiring, safety issues for pharmacy staff who worked alone, or a pharmacy manager’s conduct. We recommended that the Director follow the AIB’s recommendations and provide ethics training and a repercussion-free reporting system for pharmacy staff.