Combined Assessment Program Review of the VA Hudson Valley Health Care System, Montrose, New York

Report Information

Issue Date
Report Number
14-04211-94
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
19
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 215 employees. This review focused on eight operational activities. The facility complied with selected standards in the following two activities (1) coordination of care and (2) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishments were receiving national recognition and distinction from The Joint Commission’s Top Performer on Key Quality Measures® program and establishing a Registered Nurse Transition Care Management Program. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) environment of care, (3) medication management, (4) magnetic resonance imaging safety, (5) acute ischemic stroke care, and (6) emergency airway 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 facility managers ensure licensed independent practitioners trained to perform airway management are fully privileged.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility complete the conversion from the six-part credentialing and privileging folder to the two-part privileging folder.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Emergency Response Committee document review of each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure public restrooms are free of insects and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility clean and/or repair dirty/damaged wheelchairs in patient care areas or remove them from service.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure walk-off sticky mats are in place at construction site entrances to minimize dust, ensure site entrances are secured, and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility not stock heparin in concentrations of more than 5,000 units per milliliter in patient care areas or document approval by the Chief of Pharmacy to stock in these concentrations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the plan for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure medications awaiting destruction are stored separately from medications available for administration and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the stroke policy to address screening for difficulty swallowing and use of the National Institutes of Health Stroke Scale and tracking of its use and that the facility managers fully implement the revised policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report to the Veterans Health Administration 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.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility comply with Veterans Health Administration directive requirements for exempted facilities, or if the facility plans intubations during emergency responses, they comply with Veterans Health Administration requirements for non-exempted facilities.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure a provider with completed emergency airway management privileges or a clinician with completed emergency airway management scope of practice is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure video laryngoscopes are available in all designated locations and monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.