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

Report Information

Issue Date
Report Number
16-00558-311
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care delivered at the Syracuse VA Medical Center. This included reviews of aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home (CNH) Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 97 employees. OIG identified certain system weaknesses in credentialing and privileging, transfer data collection and documentation, trending reversal agent use in moderate sedation cases and processing adverse events/complications, history and physical examinations for moderate sedation procedures, moderate sedation training, CNH Oversight Committee and clinical visits, review of Patient Record Flags placed for disruptive/violent behavior, employee training to prevent and manage disruptive/violent behavior, and medication room security. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Has an effective Ongoing Professional Practice Evaluation process (2) Has a safe inter-facility transfer process (3) Has a process to ensure collection of information to improve moderate sedation care, ensures providers review patients’ history of previous adverse experiences with sedation/anesthesia prior to moderate sedation, and ensures providers have training to perform moderate sedation (4) Effectively oversees the CNH program (5) Reviews flags placed in patient records for disruptive/violent behavior and has an effective process to train employees to prevent and manage these behaviors (6) Effectively secures medications in the intensive care unit from unauthorized access OIG made recommendations for improvement in the following five review areas: (1) Quality, Safety, and Value; (2) Coordination of Care; (3) Moderate Sedation; (4) CNH Oversight; and (5) Management of Disruptive/Violent Behavior. OIG made a recommendation for an incidental finding related to medication room access.

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 the facility collect and report data on patient transfers out of the facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, providers consistently include date of transfer and documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility trend the use of reversal agents in moderate sedation cases, that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events, and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers include the history of previous adverse experiences with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical managers ensure employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish a Community Nursing Home Oversight Committee.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure clinical visits occur within the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director immediately remove unauthorized employees’ access to the medication room, evaluate access for all medication rooms within the facility, and take corrective action to meet Veterans Health Administration requirements.