Federal inspectors flag deficiencies at VA medical center in Leeds 

  • U.S. Senator Elizabeth Warren poses with James Cassidy of East Longmeadow during her visit to the VA Central Western Massachusetts Healthcare System in Leeds on Friday, September 8, 2017.

Staff Writer
Published: 1/21/2020 11:36:14 PM

NORTHAMPTON — Thirty recommendations for improving service to patients at the Veterans Affairs medical center are being implemented following a federal inspection at the Leeds facility last spring, according to hospital management.

Titled “Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System Leeds, Massachusetts,” the recently released report from the Office of the Inspector General’s Office of Healthcare Inspections details ways to improve patient safety and health care quality at the facility. In fiscal year 2018, the Leeds VA served 27,997 patients and completed 386,091 outpatient visits.

“The patient experience survey scores applicable to the facility demonstrated that patients were generally satisfied with the leadership and care provided,” John D. Daigh Jr., assistant inspector general for the health care inspections office, wrote in the cover letter of the report. “Facility leaders appeared to be actively engaged with patients through leadership rounding, where the executive team members interact with patients and staff and solicit feedback.”

Andre J. Bowser, spokesman for VA Central Western Massachusetts, issued a statement by email in response to the report, observing that what was discovered happened before last June.

“This review highlights an inspection that occurred more than six months ago,” Bowser said. “It did not identify any negative impacts to patient care,” adding that Daigh noted the general satisfaction from patients in the leadership and care.

Bowser added that the VA Central Western Massachusetts Healthcare System continually strives to improve performance, and already has plans in place to complete the recommendations from the inspector general in the near future.

While the report, which is done about every three years and follows an unannounced site visit, offers critiques, its main aim is to improve patient safety and health care quality.

The site visit began June 3 and covers a period beginning Dec. 6, 2014, and ending June 6, 2019, when the site visit concluded.

One area of concern cited was a failure by the center to notify families or guardians of the deaths of five patients in its care. The report states there were six “sentinel” events during the nearly five-year time frame, which are considered incidents or conditions that lead to “death, permanent harm, or severe temporary harm and intervention required to sustain life.”

“None of these six sentinel events had documented institutional disclosures even though five of them resulted in patient deaths, three of which were drug overdoses by the patients,” the report states. “Further, although VHA (Veterans Health Administration) requires disclosure of adverse events that cause death, the chief of staff reported that none of the five events were disclosed to the patients’ families or legal guardians.”

But Bowser said the center disputes that was the case.

“The premise of this allegation is false,” Bowser said. “Of these five sentinel events, VA Central Western Mass made proper notification to the family or legal guardians in each situation, but facility staff inaccurately documented the institutional disclosure note in our system. This issue has been addressed.”

In addition to examining the management and leadership at the VA Central Western Massachusetts, the report looked at eight clinical areas where a combined 30 recommendations were made for improvements. Those clinical areas are quality, safety and value; medical staff privileging; environment of care; medication management; mental health; geriatric care; women’s health; and high-risk processes.

As examples of the recommendations, for medication management the report advises the center to have controlled substances inspectors appointed in writing and with terms not to exceed three years, and for women’s health that cervical cancer screening data be tracked and monitored, and that the Women Veterans Health Committee meets at least quarterly.

“The number of recommendations should not be used, however, as a gauge for the overall quality provided at this facility,” the report states. “The intent is for facility leaders to use these recommendations as a road map to help improve operations and clinical care.”

In addition, while the report notes that preliminary accreditation for the VA was denied in June 2018 by The Joint Commission, the center received full accreditation two months later.

Scott Merzbach can be reached at smerzbach@gazettenet.com.


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