Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York

Report Information

Issue Date
Report Number
23-00121-158
VISN
2
State
New York
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Medical Staff Privileging Credentialing
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Finger Lakes Healthcare System, which includes the Bath and Canandaigua VA Medical Centers and multiple outpatient clinics in New York and Pennsylvania. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued three recommendations for improvement in three areas:
1.    Medical staff privileging
•    Ongoing Professional Practice Evaluations - equivalent specialized training and similar privileges

2.    Environment of care
•    Environment of care inspections

3.    Mental health
•    Comprehensive Suicide Risk Evaluation completion

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 practitioners from other facilities with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for solo licensed independent practitioners.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff conduct environment of care inspections in non-patient care areas at least once per fiscal year.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.