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Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida

Report Information

Issue Date
Report Number
12-03075-52
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, OIG provided crime awareness briefings to 1,290 employees. This review focused on 10 operational activities. The facility complied with selected standards in the following three activities: (1) coordination of care, (2) nurse staffing, and (3) polytrauma. The facility’s reported accomplishment was receiving national recognition and awards for excellence for its Neurology Service. OIG made recommendations for improvement in the following seven activities: (1) environment of care, (2) moderate sedation, (3) medication management, (4) mental health treatment continuity, (5) colorectal cancer screening, (6) point-of-care testing, and (7) QM.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC-Safety and IC Committee minutes reflect sufficient data analysis, actions implemented, and tracking of items to closure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a comprehensive EOC inspection of the ED be conducted and that appropriate actions be taken to correct IC and safety deficiencies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that emergency exits are not obstructed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that MSDS inventory lists and hazardous materials information binders are current and that staff are trained on accessing the electronic MSDS materials.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and SCI outpatient clinic.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that medications, chemicals, solutions, and cleaning carts are properly secured.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections and daily room inspections are conducted and that inspection reports contain adequate documentation of follow-up.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all informed consents are completed appropriately and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo monthly urine drug screenings.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated timely and documented and that compliance be monitored.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients are notified of biopsy results within the required timeframe and that clinicians document notification in the EHR.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinician notification of critical test results is documented on the required template.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that local policies related to FSBG monitoring and patient management be updated to reflect actual practice.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all services complete EHR quality reviews.