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

Report Information

Issue Date
Report Number
15-00597-462
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
27
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 190 employees. This review focused on nine operational activities. The facility complied with selected standards in the following three activities: (1) advance directives, (2) surgical complexity, and (3) emergency airway management. The facility’s reported accomplishment was the Bay Shore Community Based Outpatient Clinic Collaborative Unified Behavioral Health Center. OIG made recommendations for improvement in the following six activities: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) computed tomography radiation monitoring, and (6) 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 the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassesses observation criteria and utilization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the CPR Committee review each code episode.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group document its review of National Surgical Office reports.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility keep the recipient list for the automated Critical Incident Tracking Notification e-mail current.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility review the quality of entries in the electronic health record at least quarterly.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the quality control policy for scanning include a complete review of scanned documents to ensure readability and retrievability and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the observation bed policy to reflect Veterans Health Administration policy and current practice.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Infection Control Committee consistently document analysis of surveillance activities and data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers delegate responsibility for cleaning non-critical equipment and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a policy/procedure/guideline for the identification of individuals entering the facility and that facility manager's monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that furniture in inpatient mental health patient care areas is compliant with the VA National Center for Patient Safety Mental Health Environment of Care Checklist and monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility maintain ventilation, temperature, and humidity levels in inpatient care areas according to Joint Commission and Centers for Disease Control and Prevention guidelines and VA policy to provide a safe environment for patients, staff, and visitors and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a list of resources and assets it may need during an emergency.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility¿s Emergency Operations Plan include the management of a potential increase in demand for clinical services for patients who are geriatric or disabled or have serious chronic conditions or addictions and the management of mental health services during an emergency.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop and implement a process for managing and labeling high-alert medications and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility develop policies and procedures for managing and reviewing revised computed tomography protocols.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a medical physicist review all revised computed tomography protocols and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that radiologists ensure all computed tomography reports contain the radiation dose and that facility managers monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees submit timely work orders for items needing repair and that program managers ensure deficiency correction.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees perform and document contraband inspections and that program managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Substance Abuse Residential Rehabilitation Treatment Program managers ensure that the program has written agreements in place acknowledging resident responsibility for medication security.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program managers ensure that closed circuit television does not monitor treatment activities.