Breadcrumb

Combined Assessment Program Review of the North Florida/South Georgia Veterans Health System, Gainesville, Florida

Report Information

Issue Date
Report Number
12-04190-89
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 442 employees. This review focused on seven operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following three activities: (1) environment of care, (2) medication management – controlled substances inspections, and (3) nurse staffing. The facility’s reported accomplishments were hospice and palliative care education and imaging advances. OIG made recommendations for improvement in the following four activities and the follow-up review area: (1) quality management, (2) coordination of care – hospice and palliative care, (3) long-term home oxygen therapy, (4) preventable pulmonary embolism, and (5) follow-up on environment of care issue.

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 FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the local observation bed policy be revised to include all required elements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff perform continuing stay reviews for at least 75 percent of acute care patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Emergency Effectiveness Committee reviews individual resuscitation events.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the review of EHR quality includes all services.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the blood usage review process includes the results of proficiency testing done by the laboratory.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended processes be strengthened to ensure that the PCCT includes a dedicated nurse and administrative support person.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all designated staff complete respirator fit testing.