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Combined Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida

Report Information

Issue Date
Report Number
14-00689-142
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
9
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 331 employees. This review focused on nine operational activities. The facility complied with selected standards in the following five activities: (1) nurse staffing, (2) community living center resident independence and dignity (3) management of test results, (4) suicide prevention program, and (5) management of workplace violence. The facility’s reported accomplishments were the increased use of mobile technologies in patient care and participation in a project to automate reusable medical equipment processing. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspection program, and (4) Mental Health Residential Rehabilitation Treatment Program.

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 completed within the timeframe required by facility bylaws.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC Committee and Administrative Executive Committee minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that medication/supply carts are secured at all times and that compliance be monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Nursing Service is represented at Radiation Safety Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers initiate timely actions to address deficiencies identified during annual physical security surveys.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that pharmacy inspections are consistently completed on the same day they were initiated and that compliance be monitored.
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, daily public area inspections and bed checks, and weekly contraband inspections are completed and documented and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that medications in resident rooms on the MH RRTP units are secured and daily inspections for this are documented and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that written agreements acknowledging MH RRTP resident responsibility for medication security are documented and that compliance be monitored.