Comprehensive Healthcare Inspection Program Review of the VA Hudson Valley Health Care System, Montrose, New York

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Hudson Valley Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The OIG also provided crime awareness briefings to 107 employees. The Facility has generally stable executive leadership and active engagement with employees and patients. Organizational leadership supports patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the most current “4-Star” rating. The OIG noted findings in three areas of clinical operations reviewed and issued six recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations (2) Environment of Care • Attendance on environment of care rounds • Environmental cleanliness, safety, and infection control in patient care areas • Patient Safety in the Acute Mental Health Unit showers (3) Medication Management: Controlled Substances Inspection Program • Same-day completion of physical inventories of the controlled substance storage areas • Correction of deficiencies identified during annual physical security survey of the controlled substance storage areas