Comprehensive Healthcare Inspection Program Review of the Miami VA Healthcare System, Miami, Florida

Report Information

Issue Date
Report Number
17-01756-86
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
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 delivered in the inpatient and outpatient settings of the Miami VA Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health (MH) Residential Rehabilitation Treatment Program. OIG also provided crime awareness briefings to 79 employees. The facility has stable executive leadership and active engagement with employees and patients. Organizational leaders supported patient safety, quality care, and other positive outcomes by enacting processes and plans to maintain positive perceptions of the facility through active stakeholder engagement. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Senior leaders were knowledgeable about selected SAIL metrics and continue to take actions to improve care and performance. OIG noted findings in six of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) QSV • Review of credentialing and privileging data every 6 months • Physician utilization management advisor’s documentation of decisions (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and reporting (3) EOC • EOC rounds attendance and frequency • Locked MH unit panic alarm testing (4) High-Risk Processes: Moderate Sedation • Informed consent notification of provider changes and documentation (5) Long-Term Care: CNH Oversight • CNH Oversight Committee requirements • Annual reviews of CNHs • Cyclical clinical visits (6) MH Residential Rehabilitation Treatment Program • Daily room inspections for unsecured medications

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)
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures patient transfer data for transfers out of the facility are collected, analyzed, and reported to an identified quality oversight committee and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record, and the Chief of Staff monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representation by all required disciplines, and demonstrates integration with the facility quality improvement program, and the Chief of Staff monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures the Community Nursing Home Review Team completes the required annual reviews for the community nursing homes and monitors managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees in units 5A and 5D conduct and document daily resident room inspections for unsecured medications and monitors compliance.