Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-00025-144 

Combined Assessment Program
 

Review of the
 

VA Caribbean Healthcare System
 

San Juan, Puerto Rico
 

April 14, 2011
 

Washington, DC 20420
 
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal activity to 

the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Glossary 

ACLS Advanced Cardiac Life Support 

BLS Basic Life Support 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CEB Clinical Executive Board 

CLC community living center 

COC coordination of care 

CPR cardiopulmonary resuscitation 

CPRS Computerized Patient Record System 

EOC environment of care 

facility VA Caribbean Healthcare System 

FY fiscal year 

IC infection control 

MDRO multidrug-resistant organisms 

MH mental health 

MSDS material safety data sheet 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PI performance improvement 

QM quality management 

RCA root cause analysis 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Table of Contents
 

Page
 

Executive Summary ................................................................................................... i
 

Objectives and Scope................................................................................................ 1
 

Objectives ............................................................................................................... 1
 

Scope...................................................................................................................... 1
 

Reported Accomplishments...................................................................................... 2
 

Results ........................................................................................................................ 3
 

Review Activities With Recommendations .............................................................. 3
 

QM..................................................................................................................... 3
 

Management of Test Results............................................................................. 4
 

EOC................................................................................................................... 5
 

COC .................................................................................................................. 6
 

Follow-Up on Customer Service Training .......................................................... 7
 

Review Activities Without Recommendations ......................................................... 8
 

Management of MDRO...................................................................................... 8
 

Medication Management ................................................................................... 8
 

Physician C&P................................................................................................... 8
 

Comments................................................................................................................... 9
 

Appendixes 

A. Facility Profile .................................................................................................... 10
 

B. Follow-Up on Previous Recommendations........................................................ 11
 

C. VHA Satisfaction Surveys ................................................................................. 14
 

D. VISN Director Comments .................................................................................. 15
 

E. Facility Director Comments ............................................................................... 16
 

F. OIG Contact and Staff Acknowledgments ......................................................... 21
 

G. Report Distribution ............................................................................................ 22
 

VA OIG Office of Healthcare Inspections 
Executive Summary: Combined Assessment Program
 

Review of the VA Caribbean Healthcare System,
 

San Juan, PR
 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

February 7, 2011. 

Review Results: The review covered 

seven activities and one follow-up 

review area. We made no 

recommendations in the following 

activities: 

	 Management of Multidrug-Resistant 

Organisms 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

The facility’s reported accomplishments 

were improved access to care through 

the telehealth program and earning 

several special designations and 

certifications. 

Recommendations: We made 

recommendations in the following four 

activities and follow-up review area: 

Quality Management: Ensure that 

mandatory reports are submitted 

quarterly to the Clinical Executive Board 

for review. Require that airway 

assessments are documented prior to 

procedures requiring moderate sedation 

and that compliance is monitored. 

Establish a process to collect and 

analyze all required data elements and 

review each resuscitation event for 

performance improvement opportunities. 

Management of Test Results: Ensure 

that normal test results are consistently 

communicated to patients and that 

compliance is monitored. Consistently 

use the required template to document 

communication of test results, and 

consistently monitor the process of 

communicating test results to providers 

and patients for effectiveness. 

Environment of Care: Complete and 

document annual N95 respirator fit 

testing and bloodborne pathogens 

training. Ensure material safety data 

sheet logs are consistently updated. 

Coordination of Care: Ensure that 

advance directive notifications and 

screenings are consistently documented 

in the electronic medical record and that 

screenings are accurate. 

Follow-Up on Customer Service 

Training: Ensure that mandatory 

customer service training is completed 

and monitored. 

Comments 

The Veterans Integrated Service 

Network and System Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Objectives and Scope
 

Objectives
 

Scope
 

CAP reviews are one element of the OIG’s efforts to ensure 

that our Nation’s veterans receive high quality VA health care 

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities and follow-up review area. 

	 COC 

	 EOC 

	 Follow-Up on Customer Service Training 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FYs 2008–2010 

and for FY 2011 through February 7, 2011, and was done in 

accordance with OIG standard operating procedures 

for CAP reviews. We also followed up on selected 

recommendations from our prior CAP review of the facility 

(Combined Assessment Program Review of the VA 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Caribbean Healthcare System, San Juan, Puerto Rico, 

Report No. 07-02948-81, February 21, 2008). (See 

Appendix B for further details.) The facility had a repeat 

finding in the area of customer service training. 

During this review, we also presented crime awareness 

briefings for 2,613 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments
 Telehealth	 Telehealth care utilizes medical information from CPRS and 

telecommunications technology. It encompasses diagnosis, 

treatment, follow-up, and education. The facility’s Care 

Coordination Home Telehealth program delivers care to 

1,156 veterans at home and has been successful in 

improving patient outcomes in specific areas, increasing 

access to care, and reducing waiting times and emergency 

room and clinic visits. The program moves care from a 

provider-centric model toward a patient-centered model that 

sees the home as the preferred place of care. By improving 

access to care and reducing unnecessary travel, the 

program aims to improve the patient’s overall health care 

outcomes and quality of life. Currently, the facility is utilizing 

telehealth at the Ponce and Mayaguez outpatient clinics; the 

Arecibo, St. Thomas, St. Croix, and Guayama CBOCs; and 

the Utuado and Vieques rural clinics. 

Special	 The facility is the first local institution to have its nursing 

Designations and education department earn the certificate of accreditation 

from the American Nurses Credentialing Center and is the Certifications largest American Heart Association BLS and ACLS 

Community Training Center in Puerto Rico. Additionally, the 

facility earned the designation of Accredited Chest Pain 

Center from the Society of Chest Pain Centers and is the 

only facility in the Caribbean with this designation. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Results 

Review Activities With Recommendations 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement. 

QM Oversight. Local policy requires quarterly submission of 

Blood Bank and Transfusion Committee reports and patient 

safety and mortality assessment reports. VHA requires each 

facility to provide oversight to ensure that QM components 

are implemented, integrated, and documented.1 The facility 

utilized both the CEB and the PI Board to provide oversight 

of QM activities. We found that committees appropriately 

analyzed data for PI opportunities; however, results of these 

activities were not consistently submitted to the CEB for 

review. Mandatory reports were submitted for only 1 of the 

past 4 quarters for the Blood Bank and Transfusion 

Committee and 3 of the past 4 quarters for patient safety and 

mortality assessment. 

Moderate Sedation. VHA requires providers to document a 

complete history and physical within 30 days of a procedure 

and to re-evaluate the patient immediately prior to sedation.2 

These evaluations must include an assessment of the 

airway. We reviewed the medical records of 10 patients who 

underwent selected procedures where moderate sedation 

was used and found that only eight of the pre-sedation 

evaluations contained airway assessments. 

Resuscitation Outcomes. VHA requires that each facility 

have a policy mandating the membership and responsibilities 

of a CPR committee or its equivalent.3 The facility CPR 

Committee, formed in January 2011, is responsible for 

review of individual cardiopulmonary arrests occurring at the 

facility as well as oversight review of aggregate data to 

identify and address any trends. We found that data on 

1 VHA Directive 2009-043, Quality Management System, September 11, 2009.
 2 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006.
 3 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Recommendations 

Management of 

Test Results 

malfunctioning equipment, errors or deficiencies in 

technique, and delays in initiating CPR was not collected. 

Additionally, the committee did not review individual CPR 

event outcomes. 

1. We recommended that processes be strengthened to 

ensure that mandatory reports are submitted quarterly to the 

CEB for review. 

2. We recommended that processes be strengthened to 

ensure that airway assessments are documented prior to 

procedures requiring moderate sedation and that compliance 

is monitored. 

3. We recommended that the CPR Committee establish a 

process to collect and analyze all required data elements 

and review each resuscitation event for PI opportunities. 

The purpose of this review was to follow up on a previous 

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.4 

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following areas 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.5 We reviewed the medical 

records of 20 patients who had normal results and found that 

15 of the 20 records contained documented evidence that 

the facility had communicated the results to the patients. 

Documentation of Test Result Communication. Facility 

policy requires that diagnostic laboratory, pathology, and 

radiology clinicians use a specific template to document in 

the medical record the time and means of critical test result 

communication and the name of the ordering provider 

contacted. We reviewed the medical records of 25 patients 

who had critical results and found documentation of ordering 

4 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 5 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

provider notification in all 25 records; however, the template 

required by the facility was not used. 

Monitoring Test Result Communication. VHA requires 

facilities to monitor the effectiveness of communication of 

test results to providers and patients.6 In addition, local 

policy requires that timeliness of reporting critical test/critical 

values results be monitored for PI opportunities and reported 

to the CEB quarterly. We determined that the facility 

monitored communication of critical laboratory results to 

ordering providers; however, results of these monitors were 

not reported to the CEB. Additionally, we did not find 

evidence that communication of critical radiology test results 

to providers was monitored or that communication of critical, 

abnormal, and normal test results to patients was monitored. 

Recommendations	 4. We recommended that processes be strengthened to 

ensure that normal test results are consistently 

communicated to patients and that compliance is monitored. 

5. We recommended that the required template be 

consistently used to document communication of test results. 

6. We recommended that the process of communicating 

test results to providers and patients be consistently 

monitored for effectiveness and reported. 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the medical/oncology, medical/telemetry, 

surgical intensive care, locked inpatient MH, and hospice 

units; dialysis; the emergency department; and one CLC unit. 

We also inspected the dental, chemotherapy, and women’s 

clinics; the inpatient pharmacy; interventional and general 

radiology; and nuclear medicine. The facility maintained a 

generally clean and safe environment. 

OSHA requires radiation warning labels on x-ray room doors. 

VHA requires facilities to periodically inspect the integrity of 

radiation shields and aprons.7 We found that three x-ray 

room doors in Radiology Service did not have radiation 

6 VHA Directive 2009-019.
 7 VA Radiology, “Online Guide,” <http://vaww1.va.gov/RADIOLOGY/Online_Guide.asp>, updated
 

December 20, 2007.
 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Recommendations 

COC 

warning labels. We inspected six lead aprons and found that 

only three had documented inspection dates. The facility 

corrected these conditions while we were onsite; therefore, 

we made no recommendations for these findings. However, 

we identified the following conditions that needed 

improvement. 

IC. OSHA requires that facilities using N95 respirators fit test 

designated employees annually. We reviewed the training 

records of 26 selected employees and determined that 

15 employees had the required annual fit testing. 

OSHA requires that all employees receive initial and annual 

training on the OSHA Bloodborne Pathogens Rule. We 

reviewed training records for 20 selected employees and 

found that 17 employees had this training documented for 

FY 2010. 

Environmental Safety. OSHA and The Joint Commission 

require that facilities maintain current MSDS inventory lists 

and hazardous material information for chemicals used in 

clinical areas. We reviewed 11 MSDS inventory lists and 

found that 7 of the inventory lists were current and contained 

all required information. While we were onsite, managers 

began updating the remaining MSDS inventory lists; 

however, the process was not completed in all areas. 

7. We recommended that annual N95 respirator fit testing 

and bloodborne pathogens training be completed and 

documented. 

8. We recommended that MSDS logs be consistently 

updated. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We interviewed staff and reviewed patients’ medical records 

for evidence of advance care planning, advance directives, 

and discharge instructions. We identified the following areas 

that needed improvement. 

Advance Directive Notification. VHA requires that patients 

receive written notification at each admission to a VHA 

facility regarding their right to accept or refuse medical 

treatment, to designate a Health Care Agent, and to 

document their treatment preferences in an advance 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Recommendations 

Follow-Up on 

Customer Service 

Training 

directive.8 This notification is required to be documented in 

the patient’s medical record. We reviewed the medical 

records of 20 recently discharged patients and found that 

17 of the records contained documentation that notification 

was provided at admission. 

Advance Directive Screening. VHA requires that patients be 

screened for advance directive status at each admission to a 

VHA facility and that the screening be documented in the 

medical record.9 Patients without an advance directive need 

to be asked if they would like additional information. We 

found that screening was documented for 18 of the 

20 patients whose medical records we reviewed. 

Additionally, we found that 2 of the 18 screenings were 

inaccurate relative to the existence of an advance directive. 

9. We recommended that processes be strengthened to 

ensure that advance directive notifications are consistently 

documented in the electronic medical record. 

10. We recommended that processes be strengthened to 

ensure that advance directive screenings are accurate and 

consistently documented in the electronic medical record. 

As a follow-up to a recommendation from our prior CAP 

review, we reassessed facility compliance with completion of 

customer service training. At the time of our prior review, 

local policy required all employees to complete 1 hour of 

customer service training every 3 years. VISN policy 

required new employees to complete a 6-hour class 

(Treating Veterans with CARE) within the first 90 days of 

their employment. We found that some services had less 

than 50 percent compliance with customer service training. 

We also found that only 7 (13 percent) of the 53 new 

employees whose records we reviewed had received the 

6-hour training. We recommended that the facility monitor 

completion of mandatory customer service training. 

We interviewed the Customer Service Program manager and 

reviewed committee minutes, action plans, and policies 

related to customer service. At the time of this review, local 

policy required all employees to complete 1 hour of customer 

service training every 2 years and the Treating Veterans with 

CARE training at least once. We found that 

8 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 9 VHA Handbook 1004.02. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

compliance with training was not monitored or reported after 

FY 2009. Training documentation showed that from 

October 1, 2008, to January 31, 2011, 80 percent of 

employees had completed customer service training. As of 

February 7, 2011, 60 percent of employees had completed 

the Treating Veterans with CARE training. 

Recommendation	 11. We recommended that processes be strengthened to 

ensure that mandatory customer service training is 

completed and monitored. 

Review Activities Without Recommendations
 

Management of	 The purpose of this review was to evaluate whether the 

MDRO facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We reviewed the facility’s IC risk assessment, employee 

training records, and medical records. We inspected the 

medical/oncology and infectious disease units and 

interviewed employees. We determined that the facility had 

an effective program in place. We made no 

recommendations. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of an 

intravenous chemotherapy medication and the administration 

of that medication in the outpatient chemotherapy clinic. We 

also reviewed policies and procedures and interviewed 

pharmacy and nursing employees. We determined that the 

facility safely prepared, transported, and administered the 

medications. We made no recommendations. 

Physician C&P	 The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. We made no 

recommendations. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Comments
 The VISN and Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 15–20, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix A 

Facility Profile10 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 8 

Community Based Outpatient Clinics 

Rural Clinics 

Mayaguez, PR 

Ponce, PR 

Arecibo, PR 

Guayama, PR 

St. Thomas, VI 

St. Croix, VI 

Utuado, Comerio, and Vieques, PR 

Veteran Population in Catchment Area 113,866 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

300 

 CLC/Nursing Home Care Unit 122 

 Other None 

Medical School Affiliation(s) University of Puerto Rico 

Ponce School of Medicine 

Universidad Central del Caribe 

San Juan Bautista School of Medicine 

 Number of Residents 82.9 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

November 2010) 

$459 

Prior FY (2010) 

$496 

 Medical Care Expenditures $90 $496 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

3,307 

44,761 

14,919 

3,227 

60,903 

85,597 

o CLC/Nursing Home Care Unit 6,671 40,121 

Hospital Discharges 2,789 11,437 

Total Average Daily Census (including all bed 

types) 

340.5 343.3 

Cumulative Occupancy Rate (in percent) 85 84 

Outpatient Visits 166,642 965,860 

10 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure adverse events are evaluated 

and disclosed in accordance with VHA 

policy. 

VHA policy requires that adverse 

events are evaluated, disclosed, and 

documented. The disclosure process 

is completed as required by the patient 

safety manager. 

Y N 

2. Require the peer review process to 

comply with facility and VHA policy. 

The peer review process complies with 

facility and VHA policy. 

Y N 

3. Ensure the completion of the RCA 

process in accordance with VHA policy. 

For FY 2010, RCAs were completed 

within the required timeframes. 

Y N 

4. Require the mortality review process to 

comply with VHA policy. 

A risk manager was hired to ensure 

that all mortality screening and reviews 

are completed according to VHA 

policy. Inpatient Evaluation Center 

mortality data are reviewed at 

appropriate levels. 

Y N 

5. Require the utilization management 

program to comply with VHA policy. 

Staff training was completed, and 

physician advisors were appointed. 

The utilization management program 

complies with VHA policy. 

Y N 

6. Require that high-risk area reviews and 

oversight comply with facility and VHA 

policy. 

The quality and analysis of data from 

high-risk review areas has improved. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

7. Ensure that supplies and materials are 

stored in accordance with National Fire 

Protection Association standards. 

This is monitored during EOC rounds. 

In addition, quarterly e-mails on this 

topic have been sent to staff. 

Y N 

8. Require that two fire egress doors in the 

CLC are repaired or replaced. 

This has been corrected. Y N 

9. Ensure that preventative maintenance 

inspections are appropriately completed and 

documented. 

Preventative maintenance inspections 

are monitored by Biomedical 

Engineering and reported quarterly to 

the EOC Committee. 

Y N 

10. Ensure that housekeeping closets 

containing hazardous chemicals are secured 

when unattended. 

Training has been accomplished. This 

is monitored during EOC rounds and 

reported to the EOC Committee. 

Y N 

11. Require that high-volume public 

bathrooms are cleaned frequently enough to 

maintain a safe and hygienic environment. 

An action plan was developed to 

monitor bathroom cleanliness. This 

issue is addressed during EOC rounds, 

monitored, and reported to the EOC 

Committee. 

Y N 

12. Require that ceiling tiles and ceiling tile 

grids are cleaned and replaced as needed. 

This issue is addressed during EOC 

rounds, monitored, and reported to the 

EOC Committee. 

Y N 

13. Ensure that Interim Life Safety Measures 

assessments and fire safety inspection data 

are reported to and reviewed by the EOC 

Committee. 

Interim Life Safety Measures 

assessments and fire safety inspection 

data are presented and discussed in 

EOC Committee meetings. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Customer Service Training 

14. Require that completion of mandatory 

customer service training be monitored. 

Training compliance was monitored 

and reported only through FY 2009. 

N Y (see pages 7–8) 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix C 

VHA Satisfaction Surveys
 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Inpatient 

Score 

Quarter 4 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Facility 73.5 78.6 68.3 69.6 59.8 54.3 62.1 54.3 

VISN 65.8 68.3 64.3 65.1 58.1 56.8 56.5 56.4 

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4 

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2008, 2009, and 2010. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: April 7, 2011
 

From: Director, VA Sunshine Healthcare Network (10N8)
 

Subject: CAP Review of the VA Caribbean Healthcare System,
 

San Juan, PR 

To:	 Director, Bay Pines Office of Healthcare Inspections (54SP) 

Director, Management Review Service (VHA CO 10B5 Staff) 

1. I have reviewed and concur with the findings and recommendations 

contained in the Healthcare Inspection report, as it relates to the 

Combined Assessment Program Review at the VA Caribbean Healthcare 

System. 

2. Appropriate action has been initiated and/or completed, as detailed in 

the attached report. 

(original signed by:) 

Nevin M. Weaver, FACHE 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 April 7, 2011 

From:	 Director, VA Caribbean Healthcare System (672/00) 

Subject:	 CAP Review of the VA Caribbean Healthcare System, 

San Juan, PR 

To:	 Director, VA Sunshine Healthcare Network (10N8) 

1. On behalf of the VA Caribbean Healthcare System, I want to express 

my appreciation to the Office of Inspector General (OIG), Office of 

Healthcare Inspections for their professional and comprehensive 

Combined Assessment Program Review at this facility, conducted on 

February 07–11, 2011. 

2. I concur with the findings and recommendations of this Office of 

Inspector General report. The VA Caribbean Healthcare System 

welcomes the external perspective provided by this report. The VA 

Caribbean Healthcare System’s reply outlines the actions taken in 

response to these findings. 

Wanda Mims, MBA 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Comments to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the recommendations 

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that processes be strengthened to ensure that 

mandatory reports are submitted quarterly to the CEB for review. 

Concur: We concur that the processes be strengthened to ensure that mandatory 

reports are submitted quarterly to the CEB for review. All reports have been scheduled 

for presentation in the CEB for the completion of the fiscal year and this process will be 

followed consistently. 

Target date for completion: Completed 

Recommendation 2. We recommended that processes be strengthened to ensure that 

airway assessments are documented prior to procedures requiring moderate sedation 

and that compliance is monitored. 

Concur: We concur that the processes be strengthened to ensure that airway 

assessments are documented prior to procedures requiring moderate sedation and that 

compliance is monitored. An airway assessment is already included in a standardized 

Pre-Anesthesia Assessment as part of the Anesthesia Record. This form is the only 

approved documentation template for moderate sedation. All providers with moderate 

sedation privileges have been trained on the use of this form. A modified version of the 

Pre-Anesthesia form is being presented to the record review committee in April 2011 for 

final approval. This form will be used by all providers who perform moderate sedation. 

Monthly monitoring by QM will commence upon implementation of the form. Results of 

the monitor will be seen by the Moderate Sedation Committee and the CEB. 

Target date for completion: April 2011 

Recommendation 3. We recommended that the CPR Committee establish a process 

to collect and analyze all required data elements and review each resuscitation event 

for PI opportunities. 

Concur: We concur that the CPR Committee establish a process to collect and analyze 

all required data elements and review each resuscitation event for PI opportunities. The 

Critical Care Sub Committee began meeting weekly in January 2011. Each CPR event 

is reviewed and discussed in detail with members. The team created a document to 

standardize data collection, which is in line with Joint Commission elements related to 

code analysis. The Critical Care Sub Committee reports the findings at the monthly 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Critical Care Committee meeting where trends and areas of improvement are 

discussed, and improvement opportunities identified and tracked. 

Target date for completion: Completed 

Recommendation 4. We recommended that processes be strengthened to ensure that 

normal test results are consistently communicated to patients and that compliance is 

monitored. 

Concur: We concur that the processes be strengthened to ensure that normal test 

results are consistently communicated to patients and that compliance is monitored. A 

center memorandum on the communication of test results was published in 

January 2011 prior to the OIG visit. Training on the center memorandum to Primary 

Care and other staff is scheduled on April 7, 2011. Ongoing compliance is being 

monitored by the QM office and is reported to the Patient Safety Committee and the 

CEB. 

Target date for completion: April 2011 

Recommendation 5. We recommended that the required template be consistently 

used to document communication of test results. 

Concur: We concur that the required template be consistently used to document 

communication of test results. Use of the template has been reinforced and the QM 

office has established a monitor to track compliance. The current compliance rate for 

the 2nd quarter of 2011 is 80 percent and QM reports this monitor to the Patient Safety 

Committee and the CEB. 

Target date for completion: Completed 

Recommendation 6. We recommended that the process of communicating test results 

to providers and patients be consistently monitored for effectiveness and reported. 

Concur: We concur that the process of communicating test results to providers and 

patients be consistently monitored for effectiveness and reported. Communication of 

test results has been reinforced and the QM office has established a monitor to track 

compliance. The current compliance rate for the 2nd quarter of 2011 is 80 percent. 

Findings of non-compliance are reported to the Nursing Service Performance 

Improvement Coordinator for direct intervention with staff, and the QM office reports the 

monitor to the Patient Safety Committee and the CEB. 

Target date for completion: Completed 

Recommendation 7. We recommended that annual N95 respirator fit testing and 

bloodborne pathogens training be completed and documented. 

Concur: We concur that the annual N95 respirator fit testing and bloodborne pathogens 

training be completed and documented. To improve compliance, the respirator 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

database will be monitored on a monthly basis to ensure that annual fit testing is 

completed in a timely manner. Supervisors are being provided a list identifying 

employees who are due to have a fit test to ensure employees are scheduled for the fit 

testing. As of March 2011, 93 percent of employees have been fit tested. The 

remaining will be fit tested by April 30, 2011. The bloodborne pathogens training is 

provided as part of New Employee Orientation and during mandatory training fairs, and 

the compliance rate is monitored by Education Service. 

Target date for completion: April 2011 

Recommendation 8. We recommended that MSDS logs be consistently updated. 

Concur: We concur that the MSDS logs be consistently updated. A meeting with safety 

representatives from each area is being conducted and a standardized MSDS binder 

format is being implemented. 

Target date for completion: April 2011 

Recommendation 9. We recommended that processes be strengthened to ensure that 

advance directive notifications are consistently documented in the electronic medical 

record. 

Concur: We concur that the processes be strengthened to ensure that advance 

directive notifications are consistently documented in the electronic medical record. The 

Chief of Health Administration Service and the Supervisor of Admissions will ensure that 

VA form 672-02-03-10-122 Rev., “Patient Acknowledgement of Admission and D/C 

Planning Issues” is scanned in the veteran’s medical record. A monitor has been 

established to track compliance. The achievement level for this monitor is 95 percent 

and this monitor will be reported to the PI Board. 

Target date for completion: September 2011 

Recommendation 10. We recommended that processes be strengthened to ensure 

that advance directive screenings are accurate and consistently documented in the 

electronic medical record. 

Concur: We concur that processes be strengthened to ensure that advance directive 

screenings are accurate and consistently documented in the electronic medical record. 

The Chief of Health Administration Service and the Supervisor of Admissions will 

ensure that VA form 672-02-03-10-122 Rev., “Patient Acknowledgement of Admission 

and D/C Planning Issues” is scanned in the veteran’s medical record. Nursing in-patient 

supervisors will ensure compliance with advance directive screening. A monitor has 

been established to track compliance. The achievement level for this monitor is 

95 percent and this monitor will be reported to the PI Board. 

Target date for completion: September 2011 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Recommendation 11. We recommended that processes be strengthened to ensure 

that mandatory customer service training is completed and monitored. 

Concur: We concur that the processes be strengthened to ensure that mandatory 

customer service training is completed and monitored. A system has been established 

to report and monitor compliance with customer service training. Reports will be 

submitted to the Customer Service Committee and Executive Leadership Board 

monthly. To date, 85 percent of staff have received mandatory customer service 

training. 

Target date for completion: August 2011 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 Christa Sisterhen, MCD, Director 

Bay Pines Office of Healthcare Inspections 

Contributors	 Alice Morales-Rullan, RN, Team Leader 

Darlene Conde-Nadeau, NP 

David Griffith, RN 

Karen McGoff-Yost, LCSW 

Carol Torczon, ACNP 

Idell Graham, Program Support Assistant 

Dave Spilker, Office of Investigations 

Kenneth Velazquez, Office of Investigations 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the VA Caribbean Healthcare System, San Juan, PR 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Sunshine Healthcare Network (10N8) 

Director, VA Caribbean Healthcare System (672/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

Resident Commissioner for the Commonwealth of Puerto Rico: Pedro Pierluisi 

Delegate to Congress from the U.S. Virgin Islands: Donna M. Christian-Christensen 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA OIG Office of Healthcare Inspections 22