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Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania

Report Information

Issue Date
Report Number
13-02641-50
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 265 employees. This review focused on seven operational activities. The facility complied with selected standards in the following four activities: (1) quality management, (2) medication management – controlled substances inspections, (3) coordination of care – hospice and palliative care, and (4) nurse staffing. The facility’s reported accomplishments were the implementation of a team-based outpatient mental health model of care and a promotional video that featured the Dementia Competencies at Home Program. OIG made recommendations for improvement in the following three activities: (1) environment of care, (2) construction safety, and (3) Mental Health Residential Rehabilitation Treatment Program.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Environmental Management Service closets are secured at all times.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that ceiling tiles are promptly replaced and that compliance be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that contractors receive OSHA Construction Safety training prior to project initiation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure construction sites are secured against unauthorized access and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the cause of the pooling water outside the shower on unit 7A be fixed and the identified handicapped bathroom door on unit 7A be hung correctly and that processes be strengthened to ensure that units 7A, 8A, 8B, and 39A are clean and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that monthly self-inspections are conducted on all MH RRTP units and documented and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that medications in resident rooms on units 7A, 8A, and 8B are secured and that compliance be monitored.