This review provides a focused evaluation of the quality of care delivered at the Coatesville VA Medical Center, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus 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. The executive leadership team appeared stable and engaged as they worked to sustain and improve employee and patient engagement and satisfaction. Review of accreditation organizational findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Executive Leadership Board was not following actions until completion. The leaders were aware of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to maintain and improve performance contributing to the SAIL “5-star” and CLC “2-star” quality ratings. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Implementation of corrective actions from root cause analyses (2) Medical Staff Privileging • Medical Executive Board review/recommendation of privileging actions (3) Environment of Care • Environmental cleanliness • Inventory of resources and assets for emergency management • Generator testing (4) Controlled Substances Inspections • Inspector appointments and competencies • Verification of controlled substance orders (5) Mental Health • Military sexual trauma training (6) Geriatric Care • Patient/caregiver understanding of medication education (7) Women’s Health • Women Veterans Health Committee membership (8) Emergency Departments and Urgent Care Centers (UCC) • Waiver for 24-hour operations • Registered nurse staffing • Availability of support services (9) Incidental Finding • Ambulance transportation of emergent patients to UCC
Coatesville, PA
United States
