Report Summary

Title: Comprehensive Healthcare Inspection Program Review of the Bath VA Medical Center, Bath, New York
Report Number: 17-01752-32 Download
Issue Date: 12/7/2017
City/State: Bath, NY
Elmira, NY
Wellsville, NY
Coudersport, PA
Wellsboro, PA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP Report
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Bath VA Medical Center (facility). This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 29 employees.

The facility has generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors.

OIG noted findings in five of the six areas of clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:

(1) Quality, Safety, and Value

• Credentialing and privileging data reviews

• Utilization management documentation

(2) Medication Management: Anticoagulation Therapy

• Provision of medication education to patients

(3) Environment of Care

• Environment of care rounds frequency and attendance

• Maintenance of required number of filled oxygen tanks and an adequate supply of personal protective equipment

• Storage of clean and sterile supplies

(4) Mental Health Residential Rehabilitation Treatment Program

• Monthly self-inspections, weekly contraband inspections, every 2-hour rounds of public spaces, and daily resident room inspections

• Security at entrance doors