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

Report Information

Issue Date
Report Number
14-02084-16
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a review 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 1,792 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) medication management and (2) coordination of care. The facility’s reported accomplishments were receipt of the Veterans Health Administration National Best Practice Showcase Certificate of Excellence for outstanding achievements in developing the Patient Aligned Care Team at the William “Bill” Kling VA Clinic and same day access to the Mental Health Fast Track clinic for veterans needing urgent psychiatric care. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) acute ischemic stroke care, (4) community living center resident independence and dignity, and (5) magnetic resonance imaging safety.

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 completed actions from peer reviews are consistently documented in Peer Review Committee meeting minutes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Blood Utilization Committee representative from Anesthesia Service consistently attends meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the negative pressure control systems in the dialysis isolation rooms are functional and that the dialysis unit water treatment, sterile supply, clean utility, and soiled utility room doors are secured at all times 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 equipment is not stored in the restraint room on the locked mental health unit and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that documentation of pachymetry probe reprocessing in the eye clinic is in accordance with the manufacturer’s instructions and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient 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 clinicians screen patients for difficulty swallowing prior to oral intake.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans, document resident progress towards restorative nursing goals, and document reasons why care planned restorative nursing services were not provided or were discontinued and that compliance be monitored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all potential contraindications prior to the scan and that compliance be monitored.