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Combined Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York

Report Information

Issue Date
Report Number
13-03620-102
VISN
State
New York
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 74 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) coordination of care, and (3) community living center resident independence and dignity. The facility’s reported accomplishments were a revamped Systems Redesign program, the Green Award, and the Computed Tomography Optimization Project. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) nurse staffing, and (4) pressure ulcer prevention and management.

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 continuing stay reviews are performed on at least 75 percent of patients in acute beds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly, include the Chief of Staff and VASQIP nurse as members, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all occasional locked MH unit workers receive training on the proper use of the MH EOC Checklist and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff perform and document patient skin inspections and risk scales daily, upon transfer, and at discharge 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 acute care staff consistently document pressure ulcer stages and revise treatment plans when risk levels change 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 acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.