Clinical Assessment Program Review of the Orlando VA Medical Center, Orlando, Florida

Report Information

Issue Date
Report Number
16-00565-154
VISN
State
Florida
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 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.

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 implement the use of a visitors log during non-business hours and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility perform quality control testing on all endoscopes and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility review quality assurance data for the anticoagulation management program quarterly as defined by local policy and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, transferring providers consistently include documentation of patient or surrogate informed consent, VA Form 10-2649B, in transfer documentation and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers consistently complete VA Form 10-2649A for patients transferred out of the facility and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Program employees at Lake Baldwin conduct and document daily bed checks and that program managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all Mental Health Residential Rehabilitation Treatment Program emergency exit door alarms are functional and turned on at all times and that program managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all closed circuit television monitoring cameras at the Domiciliary Care for Homeless Veterans and Substance Abuse Residential Rehabilitation Treatment Programs have recording capability and that program managers monitor compliance.