Comprehensive Healthcare Inspection Program Review of the Northport VA Medical Center, New York

Report Information

Issue Date
Report Number
18-01018-281
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Northport VA Medical Center (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The current Director and the Associate Director were permanently assigned in June 2017. The former Chief of Staff and Associate Director for Patient Care Services were assigned to positions outside the Facility in August 2017, and the positions have since been filled by interim appointees. Further, opportunities appear to exist for the Director and Associate Director to provide a workplace environment where employees feel safe to bring forth issues or ethical concerns. The lack of consistent leadership oversight of quality improvement activities may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. The OIG noted findings in five of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Interdisciplinary utilization management data reviews • Implementation of root cause analysis actions and provision of feedback • Facility Leaders’ review of annual patient safety report (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) EOC • EOC rounds frequency • Pest management program • Safe and clean environment • Medical equipment safety inspection process • Mental Health seclusion room safety (4) Medication Management: CS Inspection Program • Electronic access for performing and monitoring CS balance adjustments (5) Long-Term Care: Geriatric Evaluations • Performance improvement oversight

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)
The Chief of Staff ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures implementation of root cause analysis actions and provides feedback of results to the reporting individuals or departments and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to the Facility leaders and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that Service Chiefs complete and report Focused and Ongoing Professional Practice Evaluations to the Professional Standards Board for determination of provider privileges and monitors the Service Chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures environment of care rounds are conducted in patient care areas of the Facility at the required frequency and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures a proactive pest control management program is in place throughout the Facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures that a consistent mechanism or method is in place for clinical staff to be confident that patient care equipment is safe and functional and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures the mental health seclusion room flooring provides cushioning.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that geriatric evaluation performance improvement activities are reviewed by a Facility leadership board and monitors compliance.