Combined Assessment Program Review of the James A. Haley Veterans’ Hospital, Tampa, Florida

Report Information

Issue Date
Report Number
15-04709-208
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
6
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 118 employees. This review focused on eight operational activities. The facility complied with selected standards in the following three activities: (1) medication management, (2) advance directives, and (3) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishment was receiving the Get With The Guidelines®-Stroke Gold Plus Achievement Award. OIG made recommendations for improvement in the following five activities: (1) quality, safety, and value; (2) environment of care; (3) coordination of care; (4) computed tomography radiation monitoring; and (5) suicide prevention 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 facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure damaged equipment in patient care areas is repaired or removed from service and stained/missing ceiling tiles are replaced.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.