Comprehensive Healthcare Inspection of the North Florida/South Georgia Veterans Health System, Gainesville, Florida

Report Information

Issue Date
Report Number
19-00010-237
VISN
State
Florida
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
28
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the North Florida/South Georgia Veterans Health System, covering leadership, organizational risks, and key processes associated with promoting quality care. Areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership appeared stable, with four of six positions permanently filled for over one year. Employee satisfaction and patient experience survey were similar to or higher than VHA averages. Leaders supported efforts related to safety and quality care; however, patient safety indicator data, along with missing institutional disclosure information and conflicting survey report information, may contribute to organizational risks. The leaders were knowledgeable about SAIL metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings. The OIG issued 28 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • General cleanliness, maintenance, and biohazardous waste storage • Generator testing (4) Medication Management • Monthly inspections and rotation of inspectors • Verification of orders, drugs held for destruction, prescription pads, hard copy prescriptions, and 72-hour inventories (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Women Veterans Health Committee membership and reporting • Cervical cancer screening data tracking (8) Emergency Departments/Urgent Care Center Operations • On-call social work support • Directional signage (9) Incidental Findings • Medical record scanning backlog • Post Anesthesia Care Unit cardiac monitor inspections and oxygen storage

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 all required representatives participate in the interdisciplinary review of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis and monitors patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that the identified committee reviews all resuscitative episodes and monitors the committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that clinical managers clearly define focused professional practice evaluation criteria in advance with providers and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that clinical managers include service/section-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that service chiefs’ determination to recommend continuation of privileges be based in part on results of ongoing professional practice activities and monitors service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy director confirms that facility managers maintain a safe and clean environment throughout the healthcare system and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy director ensures the furnishings in the intensive care units are repaired or replaced and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy director makes certain that medical biohazardous waste storage rooms are secured and properly identified and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy director makes certain that facility management service managers conduct weekly generator testing as required and monitors managers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors complete the monthly controlled substances inspections and physical inventory counts on the day initiated and that the controlled substances coordinator evaluates and maintains supporting documentation and monitors inspectors’ and coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures controlled substances inspectors do not inspect the same area for two or more consecutive months and monitors inspectors’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and monitors coordinator’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors verify there is a corresponding sealed evidence bag containing drug(s) for each medication listed on the “Destructions File Holding Report” during monthly inspections and monitors inspectors’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures that controlled substances inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances orders during monthly area inspections and monitors inspectors’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that controlled substances inspectors complete the verification of the twice weekly pharmacy inventory as required and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures clinicians reconcile medication information and maintain accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms that the Women Veterans Health Committee reports to an executive leadership committee and monitors the committee’s compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The chief of staff ensures that staff collect and track cervical cancer screening data and monitors staff compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director makes certain that the emergency department has on-call social work staff available to assist with patient care and monitors staff compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director confirms adequate directional signage leads patients to the emergency department and monitors staff compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The facility director ensures the chief of Health Information Management facilitates the timely scanning of clinical reports into patients’ electronic health records and monitors compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy director ensures medical equipment is evaluated per manufacturers’ recommendations and monitors compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The deputy director ensures that full and empty oxygen gas cylinders are physically separated and clearly labeled and monitors compliance.