Comprehensive Healthcare Inspection of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the VA Texas Valley Coastal Bend Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leadership team appeared relatively stable even though three of the four positions were permanently filled less than six months before the OIG’s site visit. The executive leaders had served in an acting capacity in their current position prior to being selected permanently. Employees and patients seem generally satisfied with the leadership and care provided. The facility leaders appeared actively engaged and supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG’s review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leadership team was knowledgeable within their scope of responsibility about selected SAIL metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “2-star” quality rating. The OIG issued 11 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Weekly electrical system inspections (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock (repeat finding) • Controlled substances order verifications (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Patient/caregiver understanding of education • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership