Comprehensive Healthcare Inspection of the VA NY Harbor Healthcare System in New York

Report Information

Issue Date
Closure Date
Report Number
22-04133-163
VISN
1
State
New York
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
12
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 care provided at the VA NY Harbor Healthcare System. The system includes three medical centers located in Brooklyn, Manhattan, and Queens and two outpatient clinics in New York. This evaluation focused on five key operational areas: • Leadership and organizational risks • Quality, safety, and value • Medical staff privileging • Environment of care • Mental health (focusing on suicide prevention initiatives) The OIG issued 12 recommendations for improvement in four areas: 1. Quality, safety, and value • Peer review aspects of care • Peer Review Committee recommendations • Communication and implementation of recommendations 2. Medical staff privileging • Service-specific criteria in professional practice evaluations 3. Environment of care • Inspections • Deficiency monitoring until resolution • Over-the-door alarm testing • Hazard warning signs • Safety and cleanliness 4. Mental health • Suicide-related events reporting • Comprehensive Suicide Risk Evaluations • Notification of suicidal behaviors

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: 3/29/2024

The Executive Chief of Staff ensures peer reviewers identify at least one aspect of care when assigning a Level 2 or 3 to a peer review.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2024

The Executive Chief of Staff ensures the Peer Review Committee recommends improvement actions to reviewed providers.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2024

The Executive Chief of Staff ensures supervisors communicate the Peer Review Committee’s recommendations to providers and ensure they implement improvement actions for all Level 2 and 3 peer reviews.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2024

The Executive Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2025

The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2025

The Deputy Medical Center Director ensures the Comprehensive Environment of Care Coordinator or designee monitors environment of care inspection deficiencies until resolution.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2024

The Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on inpatient mental health unit sleeping room doors.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2024

The Deputy Medical Center Director ensures staff post hazard warning signs in all areas where potentially infectious materials are located.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2024

The Deputy Medical Center Director ensures staff keep patient care areas safe and clean.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2025

The Executive Chief of Staff ensures suicide prevention coordinators report suicide-related events to mental health leaders and quality management staff at least monthly

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2024

The Executive Chief of Staff ensures designated staff complete a Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2024

The Executive Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.