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

Report Information

Issue Date
Report Number
13-01971-245
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 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 136 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) coordination of care – hospice and palliative care, (2) pressure ulcer prevention and management, and (3) nurse staffing. The facility’s reported accomplishments were implementation of an innovative medication safety curriculum and the Comprehensive Pain Center, which offers interdisciplinary pain rehabilitation programs. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) medication management – controlled substance inspections, and (4) construction 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 all services are included in the review of EHR quality.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the MH units, corrective actions taken, and tracking of corrective actions to closure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that sterile storage rooms are secured at all times and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff competency validation results and results of compliance with RME SOPs are reported to the Clinical Executive Board.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that SPS employees responsible for reprocessing activities have initial training and annual competency validation documented.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that OR employees who perform immediate use sterilization have initial training and annual competency validation documented.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the SPS eyewash station is checked weekly 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 the SPS decontamination area is clean.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that monthly CS findings summaries and quarterly trend reports are provided to the facility Director consistently and timely.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all non-pharmacy areas with CS are inspected monthly 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 IC and tuberculosis risk assessments are conducted prior to construction project initiation.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in IC Committee minutes.