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

Report Information

Issue Date
Report Number
14-00688-162
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 116 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) quality management, (2) medication management – controlled substances inspection program, and (3) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishment was the Mobile Adult Day Health Care Outreach Program. OIG made recommendations for improvement in the following four activities: (1) environment of care, (2) nurse staffing, (3) community living center resident independence and dignity, and (4) management of test results.

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 EOC Work Group minutes reflect that actions are taken in response to identified deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a policy for the safe use of fluoroscopic equipment and that compliance with the newly established policy be monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated x-ray/fluoroscopy employees receive annual fluoroscopy safety training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that restorative nursing staff consistently document weekly and monthly notes according to local policy 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 providers are notified of critical laboratory and abnormal radiology test results/values within the expected timeframe and that notification is documented in the EHRs.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the EHRs.