Report Summary

Title: Clinical Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida
Report Number: 16-00565-154
Issue Date: 4/13/2017
City/State: Orlando, FL
Clermont, FL
Daytona Beach, FL
Kissimmee, FL
Orange City, FL
Tavares, FL
Viera, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CAP Reviews
Release Type: Unrestricted
Summary: The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the Orlando VA Medical Center. 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; Community Nursing Home Oversight; Management of Disruptive/Violent Behavior; and Mental Health Residential Rehabilitation Treatment Program. OIG also provided crime awareness briefings to 477 employees. OIG identified certain system weaknesses in credentialing and privileging, environmental safety, endoscope processing, anticoagulation quality control, transfer documentation, the disruptive behavior program, and Mental Health Residential Rehabilitation Treatment Program safety measures. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Has an effective process for reviewing Ongoing Professional Practice Evaluation data; (2) Maintains a clean and safe environment of care; (3) Has an effective process for reviewing anticoagulation quality assurance data; (4) Has a safe patient transfer process; (5) Effectively manages disruptive/violent behavior incidents and ensures employees receive training; (6) Maintains a safe Mental Health Residential Rehabilitation Treatment Program environment. 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) Mental Health Residential Rehabilitation Treatment Program.