Combined Assessment Program Review of the Coatesville VA Medical Center, Coatesville, Pennsylvania

Report Information

Issue Date
Report Number
15-04708-115
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
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 183 employees. This review focused on eight operational activities. The facility complied with selected standards in the following four activities: (1) medication management, (2) coordination of care, (3) computed tomography radiation monitoring, and (4) advance directives. The facility’s reported accomplishment was establishing a Mobile Veterans Program to serve veterans who choose to receive care in the home and community rather than an institution. OIG made recommendations for improvement in the following four activities: (1) quality, safety, and value; (2) environment of care; (3) suicide prevention program; and (4) 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 facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Patient Safety Manager submit an annual patient safety report to facility leaders at the completion of each fiscal year.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise its protected peer review policy to be consistent with Veterans Health Administration policy and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Power of Women Embracing Recovery Program have a Class K fire extinguisher available in the kitchen used by residents.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Domiciliary Care for Homeless Veterans Program, Post-Traumatic Stress Disorders Residential Rehabilitation Treatment Program, and Substance Abuse Treatment Unit employees consistently perform and document contraband inspections, daily bed checks, and resident room inspections for unsecured medications and that program/unit managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Domiciliary Care for Homeless Veterans Program and Substance Abuse Treatment Unit managers ensure residents secure medications in their rooms and monitor compliance.