Comprehensive Healthcare Inspection of the Samuel S. Stratton VA Medical Center in Albany, New York

Report Information

Issue Date
Report Number
23-00011-73
VISN
2
State
New York
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
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
10
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 Samuel S. Stratton VA Medical Center and associated 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 (suicide prevention initiatives)

The OIG issued 10 recommendations for improvement in the following topic areas:
•    Medical Staff Privileging
1.    Service-specific criteria
2.    Equivalent specialized training and similar privileges

•    Environment of care
1.    Inspection scheduling, completion, and documentation
2.    Police response times to panic alarm testing
3.    Installation and testing of over-the-door alarms for sleeping room doors in the mental health inpatient unit
4.    Safe environment in the mental health inpatient unit
5.    Patient care areas safe and clean

•    Mental health
1.    Comprehensive Suicide Risk Evaluation completion after positive suicide risk screen
2.    Suicide prevention outreach activities

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

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

The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations.

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

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

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

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

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Medical Center Director ensures staff maintain a safe environment in the mental health inpatient unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures designated staff complete the 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. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.