Healthcare Facility Inspection of the VA New Jersey Healthcare System in East Orange

Report Information

Issue Date
Report Number
25-00242-195
VISN
1
State
New Jersey
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Appointment Scheduling and Wait Times
Care Coordination
Community Care
Healthcare Infrastructure
Maintenance and Construction
Patient Care Services Operations
Patient Safety
Staffing
Supplies and Equipment
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA New Jersey Healthcare System in East Orange.

This evaluation focused on five key domains: 
     •    Culture 
     •    Environment of care 
     •    Patient safety 
     •    Integrated veteran care 
     •    Veteran-centered safety net

The OIG made 11 recommendations for VA to correct identified issues in two domains: 
     •    Environment of care 
       o    Safety and cleanliness 
       o    Airflow testing in supply rooms 
       o    Temperature and humidity monitoring 
       o    Fire doors and fire safety inspections 
       o    Sprinkler system testing 
       o    Prevention of repeat findings 
     •    Patient safety 
       o    Service-level workflows for the communication of test results 
       o    Root cause analysis improvement actions 
       o    Adverse events and institutional disclosures
 

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 Director takes appropriate actions to strengthen staff accountability for maintaining clean and safe patient care areas as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

No. 2
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to Veterans Health Administration (VHA)

The Director takes appropriate actions so staff validate and document airflow testing in supply rooms annually as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

No. 3
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to Veterans Health Administration (VHA)

The Director takes appropriate actions so staff conduct a risk assessment to identify areas that require temperature and humidity monitoring and implement changes as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations and Veterans Health Administration Directive 1108.07(2), General Pharmacy Service Requirements.

No. 4
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to Veterans Health Administration (VHA)

The Director implements controls so staff repair or replace malfunctioning fire doors to ensure proper closure during emergencies as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

No. 5
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to Veterans Health Administration (VHA)

The Director implements measures so staff conduct all required fire safety inspections and document the results as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

No. 6
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to Veterans Health Administration (VHA)

The Director takes appropriate actions to implement measures to test sprinkler systems as required by the National Fire Protection Association’s Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, NFPA 25.

No. 7
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to Veterans Health Administration (VHA)

The Director takes appropriate actions so staff evaluate processes to prevent repeat environment of care findings and take actions as warranted.

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

The Veterans Integrated Service Network Director monitors for similar or repeat environment of care findings and takes appropriate actions so facility leaders develop and implement facility-wide corrective action plans and sustain improvements.

No. 9
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to Veterans Health Administration (VHA)

The Director takes appropriate actions so each service chief develops a workflow that describes staff members’ roles in the process of communicating test results to providers and patients as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director takes appropriate actions so staff track root cause analysis–driven improvement actions through to completion, monitor outcome measures, and implement processes to sustain improvements to comply with Veterans Health Administration National Center for Patient Safety’s Guide to Performing Root Cause Analysis.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Chief of Staff takes appropriate action for evaluation and improvement of processes to identify adverse events that warrant institutional disclosures to patients or their representatives as required by Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients.