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

Report Information

Issue Date
Report Number
14-02075-292
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a review 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 96 employees. This review focused on seven operational activities. The facility complied with selected standards in the following five activities: (1) environment of care, (2) medication management, (3) coordination of care, (4) community living center resident independence and dignity, and (5) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishments were the initiation of the Veterans Health Administration Voices national pilot program and recognition as a Top Performer on Key Quality Measures® by The Joint Commission. OIG made recommendations for improvement in the following two activities (1) quality management and (2) acute ischemic stroke care.

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 actions from peer reviews are completed and reported to the Peer Review Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Morbidity and Mortality Committee review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.