Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System, West Haven, Connecticut

Report Information

Issue Date
Closure Date
Report Number
18-04675-23
VISN
State
Connecticut
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
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Connecticut Healthcare System, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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. At the time of the OIG site visit, the executive team, except for the acting chief of staff, had been working together for over two years. The facility average for selected survey leadership questions was generally similar to the VHA average. All four patient survey results reflected better care ratings than the VHA average. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team should continue to take actions to sustain and improve performance of measures contributing to the Strategic Analytics for Improvement and Learning “5-star” and community living center “1-star” quality ratings. The OIG issued 13 recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Controlled Substances Inspections • Appointment limits of controlled substances inspectors • Rotation of controlled substance areas for inspection • Reconciliation of controlled substances dispensed from and returned to pharmacy • Routine inspections by controlled substances coordinator • Review of override reports (3) Military Sexual Trauma Follow-up and Staff Training • Primary care and mental health providers’ training (4) Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications • Medication reconciliation (5) Abnormal Cervical Pathology Results and Follow-Up • Patient notification of abnormal results

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: 10/19/2021
The chief of staff ensures that service chiefs clearly define and share in advance the expectations for the focused professional practice evaluation process with providers and monitors the service chiefs’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that service chiefs include service/section-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The chief of staff ensures that service chiefs’ determination to continue current privileges is based, in part, on results of ongoing professional practice evaluation activities and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The facility director ensures that the Medical Staff Executive Council documents consideration of focused and ongoing professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Staff Executive Council’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that an adequate number of controlled substances inspectors are appointed in writing prior to performing inspector duties to a term not to exceed three years and monitors the compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures that a controlled substances inspector does not inspect the same controlled substances area for two consecutive months and monitors inspectors’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures that monthly reconciliation of one-day’s dispensing from pharmacy to every automated dispensing cabinet and one-day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2021
The facility director ensures that the controlled substances coordinator refrains from conducting routine inspections of controlled substance storage areas and monitors inspector’s compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that the nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director confirms 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: 9/10/2020
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/10/2020
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The chief of staff ensures providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.