Comprehensive Healthcare Inspection of the Coatesville VA Medical Center, Pennsylvania

Report Information

Issue Date
Closure Date
Report Number
19-00048-48
VISN
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This review provides a focused evaluation of the quality of care delivered at the Coatesville VA Medical Center, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, 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 executive leadership team appeared stable and engaged as they worked to sustain and improve employee and patient engagement and satisfaction. Review of accreditation organizational findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Executive Leadership Board was not following actions until completion. The leaders were aware of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to maintain and improve performance contributing to the SAIL “5-star” and CLC “2-star” quality ratings. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Implementation of corrective actions from root cause analyses (2) Medical Staff Privileging • Medical Executive Board review/recommendation of privileging actions (3) Environment of Care • Environmental cleanliness • Inventory of resources and assets for emergency management • Generator testing (4) Controlled Substances Inspections • Inspector appointments and competencies • Verification of controlled substance orders (5) Mental Health • Military sexual trauma training (6) Geriatric Care • Patient/caregiver understanding of medication education (7) Women’s Health • Women Veterans Health Committee membership (8) Emergency Departments and Urgent Care Centers (UCC) • Waiver for 24-hour operations • Registered nurse staffing • Availability of support services (9) Incidental Finding • Ambulance transportation of emergent patients to UCC

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)
Closure Date: 6/22/2020
The facility director makes certain that all required representatives consistently participate in the interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director ensures that managers consistently implement corrective actions identified in root cause analyses and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The chief of staff ensures that the Medical Executive Board reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2020
The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The associate director verifies that the inventory of resources and assets that may be needed during an emergency is documented and reviewed annually and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The associate director ensures that emergency generators are tested in accordance with required standards and results are documented and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that controlled substances inspectors are appointed in writing and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that the controlled substances coordinators complete annual competency assessment of inspectors and monitors coordinators’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The facility director makes certain that the controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities and monitors coordinators’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The chief of staff makes certain that clinicians document patient and/or caregiver understanding of the education provided about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The chief of staff makes certain the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that if the urgent care center operates 24 hours a day, seven days a week, that the national director of Emergency Medicine has approved a waiver.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors the center’s compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/22/2020
The facility director ensures that support services are available to the urgent care center during all hours of operation and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The facility director makes certain the urgent care center does not receive patients via ambulance and monitors compliance.