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

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Canandaigua VA Medical Center. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Diagnostic Care; Community Nursing Home Oversight; Management of Disruptive/Violent Behavior; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. During the review, OIG provided crime awareness briefings to 151 employees. OIG identified certain system weaknesses in competency assessments for employees assigned to the anticoagulation management program; documentation of critical glucose values from point-of-care testing; Community Nursing Home Oversight Committee, annual reviews, and clinical visits; employee training in managing disruptive or violent behavior; and post-traumatic stress disorder suicide risk assessments and referrals. As a result of the findings, OIG could not gain reasonable assurance that: (1) the facility maintains competencies for employees directly involved in the management of anticoagulation therapy, (2) nursing documentation of critical point-of-care testing glucose results is communicated effectively with other nurses and members of the health care team, (3) facility leaders have effective oversight of the Community Nursing Home Program and assure the safe and effective care of patients in these remote facilities, (4) the facility effectively trains employees to manage disruptive or violent behavior, and (5) the facility mitigates risk for those who screen positive for post-traumatic stress disorder through the completion of a suicide risk assessment or the offer of referrals for further diagnostic evaluation. OIG made recommendations for improvement in the following five review areas: (1) Medication Management: Anticoagulation Therapy, (2) Diagnostic Care: Point-of-Care Testing, (3) Community Nursing Home Oversight, (4) Management of Disruptive/Violent Behavior, and (5) Post-Traumatic Stress Disorder Care.