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Comprehensive Healthcare Inspection of the Canandaigua VA Medical Center, New York

Report Information

Issue Date
Report Number
19-00037-58
VISN
2
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Major Management Challenges
Healthcare Services
Recommendations
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Canandaigua VA Medical Center, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. The areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leaders were all permanently assigned for seven months prior to the OIG’s inspection and seemed actively engaged with employees and patients. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The OIG noted continuing challenges regarding the facility’s integration with the Bath VA Medical Center to form the VA Finger Lakes Healthcare System. The leadership team were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics, but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “5-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Environment of Care • Medical equipment storage • Panic alarm testing • Environmental safety and repair • Patient information protection (2) Controlled Substances Inspections • Reconciliation of one-day’s dispensing and order verification • Controlled substances coordinator maintaining oversight (and refrain from conducting routine inspections) • Verification of hard copy prescriptions (3) Military Sexual Trauma (MST) Follow-up and Staff Training • MST coordinator responsibilities • MST mandatory training (4) Antidepressant Use among the Elderly • Education and evaluation of the education provided • Medication reconciliation (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership

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 associate director makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director makes certain that VA police conduct and document monthly panic alarm testing at the Rochester VA clinic and monitors VA police compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director makes certain that managers maintain a safe environment and ensure furnishings are in good repair at the Rochester VA clinic and monitors managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The associate director ensures that Rochester VA clinic staff secure laboratory transport boxes containing personally identifiable information and monitors clinic staff compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances program staff consistently reconcile one day’s dispensing from the pharmacy to each automated dispensing unit and monitors controlled substance inspectors’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances coordinators refrain from conducting routine inspections and monitors coordinators’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director certifies that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the Women Veterans Health Committee includes required core members and that members consistently attend meetings and monitors the committee’s compliance.