Clinical Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico

Report Information

Issue Date
Report Number
16-00551-128
VISN
State
Puerto Rico
Virgin Islands
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care provided in the inpatient and outpatient settings of the VA Caribbean Healthcare System. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Management of Disruptive/Violent Behavior; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 1,590 employees. OIG identified certain system weaknesses in utilization management processes, general safety, environmental cleanliness, anticoagulation processes, patient transfer documentation, management of disruptive/violent behavior processes and training, and post-traumatic stress disorder diagnostic evaluations. As a result of the findings, OIG could not gain reasonable assurance that: (1) physician advisors provide input for utilization management decisions, (2) information technology network rooms are secure, (3) patients receive care in a safe and clean environment, (4) clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and effectively monitor patients receiving anticoagulation therapy, (5) the facility safely transfers patients from the facility, (6) the facility effectively manages potential and actual disruptive or violent behaviors, and (7) patients with positive post-traumatic stress disorder screens receive complete and timely diagnostic evaluations. OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Management of Disruptive/Violent Behavior; and (6) Post-Traumatic Stress Disorder Care.

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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database 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 information technology network room doors at the facility and the St. Croix community based outpatient clinic are secured.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair ceiling leaks and replace stained and/or missing ceiling tiles on the locked mental health unit, in the ambulatory surgery waiting area, at the entrance of the Blind
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient nourishment refrigerators on the medicine/oncology and locked mental health units are clean and do not contain unlabeled food items and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently obtain all required baseline laboratory tests prior to initiating warfarin 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 newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patientstransferred out of the facility, providers consistently include documentation of patient or surrogate informed consent.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, sending nurses document nurse-to-nurse communication with the receiving facility.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managersensure all employees receive Level I training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of referral.