Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01099-247 

Combined Assessment Program
 

Review of the
 

Miami VA Healthcare System
 

Miami, Florida
 

August 11, 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 Miami VA Healthcare System, Miami, FL 

Glossary 

ARB Accident Review Board 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CPR cardiopulmonary resuscitation 

EN enteral nutrition 

EOC environment of care 

facility Miami VA Healthcare System 

FY fiscal year 

ILSM interim life safety measures 

JC Joint Commission 

LSC Life Safety Code 

MH mental health 

OIG Office of Inspector General 

OR operating room 

OSHA Occupational Safety and Health Administration 

PI performance improvement 

QM quality management 

RME reusable medical equipment 

RN registered nurse 

SOP standard operating procedure 

SPD Supply, Processing, and Distribution 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Table of Contents
 

Page
 

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

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

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

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

Reported Accomplishment........................................................................................ 2
 

Results ........................................................................................................................ 2
 

Review Activities With Recommendations .............................................................. 2
 

EOC................................................................................................................... 2
 

RME .................................................................................................................. 5
 

QM..................................................................................................................... 8
 

RN Competencies ............................................................................................. 9
 

Management of Workplace Violence................................................................. 9
 

Review Activities Without Recommendations ......................................................... 10
 

Coordination Of Care......................................................................................... 10
 

EN Safety .......................................................................................................... 10
 

Medication Management ................................................................................... 10
 

Physician C&P................................................................................................... 11
 

Comments................................................................................................................... 11
 

Appendixes 

A. Facility Profile .................................................................................................... 12
 

B. Follow-Up on Previous Recommendations........................................................ 13
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 15
 

D. VISN Director Comments .................................................................................. 17
 

E. Facility Director Comments ............................................................................... 18
 

F. OIG Contact and Staff Acknowledgments ......................................................... 26
 

G. Report Distribution ............................................................................................ 27
 

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

Review of the Miami VA Healthcare System, Miami, FL 

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 

April 11, 2011. 

Review Results: The review covered 

nine activities. We made no 

recommendations in the following four 

activities: 

 Coordination of Care 

 Enteral Nutrition Safety 

 Medication Management 

 Physician Credentialing and 

Privileging 

The facility’s reported accomplishment 

was a significant reduction in central line 

infections. 

Recommendations: We made 

recommendations in the following five 

activities: 

Environment of Care: Ensure all Life 

Safety Code deficiencies are assessed, 

interim life safety measure plans are 

developed as needed, and staff fire 

safety education is provided. Correct 

cleanliness deficiencies, and store clean 

and dirty supplies separately. Require 

that annual bloodborne pathogens 

training and respirator fit testing are 

completed and that unattended 

computers are locked. 

Reusable Medical Equipment: Clean 

equipment according to manufacturers’ 

instructions, and ensure standard 

operating procedures are consistent 

with those instructions. Complete 

annual competency validations for 

employees who flash sterilize. Ensure 

appropriate emergency eyewash 

stations are located in areas where 

chemicals are used and are tested 

weekly. Monitor and appropriately 

maintain airflow in reprocessing areas. 

Ensure sterilizers undergo preventive 

maintenance. Report specific reusable 

medical equipment elements quarterly 

to an executive-level committee. 

Quality Management: Ensure drug 

allergy assessments are documented 

prior to moderate sedation, and monitor 

compliance. Require resuscitation 

event elements to be collected and the 

Cardiopulmonary Resuscitation 

Committee to review all resuscitation 

event evaluations. Monitor use of the 

copy and paste functions. 

Registered Nurse Competencies: 

Ensure competency validation methods 

are documented for required skills. 

Management of Workplace Violence: 

Ensure all violent incidents involving 

employee victims are discussed at the 

Accident Review Board. 

Comments 

The Veterans Integrated Service 

Network and Facility 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 Miami VA Healthcare System, Miami, FL 

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 nine activities: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician C&P 

	 QM 

	 RME 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through April 11, 2011, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Miami VA Healthcare System, Miami, FL 

CAP review of the facility (Combined Assessment Program 

Review of the Miami VA Healthcare System, Miami, Florida, 

Report No. 08-00777-200, September 10, 2008). (See 

Appendix B for further details). We identified a repeat finding 

in EOC. 

During this review, we also presented crime awareness 

briefings to 223 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 Accomplishment
 Reduction in 

Central Line 

Infections 

A central venous catheter, commonly referred to as a central 

line, is a catheter placed into a large vein in the neck, chest, 

or groin to administer fluids or medications.1 The Central 

Line Bundle is a group of evidence-based interventions 

recommended by the Institute for Healthcare Improvement 

that are proven to result in better outcomes. 

Despite the facility’s strict adherence to the Central Line 

Bundle, the incidence of central line associated bloodstream 

infections in the intensive care units remained unacceptably 

elevated in FYs 2007 and 2008. In FY 2009, a 

multidisciplinary team analyzed the problem and then 

designed and implemented a second bundle of interventions 

aimed at improving central line care and blood collection 

techniques. These interventions resulted in an 80 percent 

reduction in central line infections from FY 2009 to FY 2010, 

with no central line infections for 11 consecutive months. 

Results 

Review Activities With Recommendations 

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. 

1 Central lines disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may 

spread to the bloodstream, and blood circulation changes and organ dysfunction may ensue, possibly leading to 

death. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Miami VA Healthcare System, Miami, FL 

We inspected the medicine, surgical intensive care, 

extended care, spinal cord injury, locked inpatient MH, and 

community living center units. We also inspected the 

emergency department; the same day surgery and 

post-anesthesia areas; and the cardiology, oncology, 

dialysis, and dental outpatient clinics. We identified the 

following conditions that needed improvement. 

Fire and Life Safety. National Fire Protection Association 

LSC standards require that doors be present to protect 

corridor openings and to resist and compartmentalize the 

passage of smoke. The JC requires that an ILSM plan be 

implemented when LSC deficiencies cannot be immediately 

corrected and that hospitals train employees to compensate 

for impaired structural or compartmental fire safety features. 

We found five patient rooms without doors on the locked 

inpatient MH unit. The doors were removed in 2010 

because of damaged hinges, and managers told us that an 

ILSM plan had not been developed. Additionally, unit 

managers had not been trained and could not verbalize the 

fire evacuation plan specific to the unit. While we were 

onsite, managers completed an ILSM plan, contracted with a 

vendor to replace the doors, and began installing doorstops 

to prevent future damage. 

The JC requires that fire alarm systems, including visual and 

auditory alarms, be tested annually. We found that while the 

fire alarm system had been inspected in 2010, the vendor 

reported that 32 audio/visual alarms could not be tested. 

Staff told us that the alarms were inoperable due to a circuit 

malfunction and that an ILSM plan was not in place while the 

audio/visual alarms were inoperable. The fire alarm vendor 

returned 17 days later to test the remaining alarms, which 

were then operable. 

The JC also requires that corridors be clear of obstructions in 

the event that emergency evacuation is necessary. In the 

medicine unit, the emergency department, and the OR 

temporary trailer, we found the egress to a fire exit 

obstructed. Facility managers immediately removed the 

obstructions from each area. 

General Cleanliness. The JC requires that areas used by 

patients be clean. During our inspection of patient care 

areas, we noted general conditions of uncleanliness needing 

improvement. In patient rooms, common areas, and 

VA OIG Office of Healthcare Inspections 3 
Recommendations 

CAP Review of the Miami VA Healthcare System, Miami, FL 

housekeeping and utility closets, we found dirt and debris on 

floors, along baseboards, and in corners. Additionally, dust 

accumulation was visible on numerous air vents. 

Infection Control. OSHA requires that employees with 

occupational exposure risk receive annual training on the 

OSHA Bloodborne Pathogens Rule. We reviewed 10 clinical 

employee and 21 Environmental Management Service 

employee training records. Only 1 of the 10 clinical 

employees and only 1 of the 21 Environmental Management 

Service employees did not have documentation of training. 

However, we noted that eight employees completed the 

training the week prior to our onsite visit and that training 

was overdue by 1 week to 3.5 years. 

OSHA also requires that facilities using N95 respirators fit 

test designated employees annually. We reviewed the 

records of 20 employees and found that 7 employees did not 

have the required annual fit testing. 

Clean/Dirty Storage. The JC requires that clean and dirty 

supplies be stored separately. We found housekeeping 

supplies, chemicals, and used gloves and rags stored in the 

clean linen supply closet on the dialysis unit. In addition, we 

found an exposed clean linen supply in a patient care area in 

the emergency department. Facility managers immediately 

separated the clean and dirty supplies. 

Patient Privacy. The Health Insurance Portability and 

Accountability Act requires confidential patient information to 

be secured. We found eight unattended computers in 

patient care areas displaying patient information. This was a 

repeat finding from our previous CAP review. 

1. We recommended that processes be strengthened to 

ensure that all LSC deficiencies are assessed, ILSM plans 

are developed as needed, and appropriate staff education is 

provided to ensure fire safety. 

2. We recommended that a comprehensive EOC 

inspection of the facility be conducted and that appropriate 

actions be taken to correct cleanliness deficiencies. 

3. We recommended that annual bloodborne pathogens 

training and N95 respirator fit testing be completed and that 

compliance be monitored. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Miami VA Healthcare System, Miami, FL 

4. We recommended that processes be strengthened to 

ensure that clean and dirty supplies are stored separately. 

5. We recommended that processes be strengthened to 

ensure that computers are locked when not attended. 

RME	 The purpose of this review was to evaluate whether the 

facility had processes in place to ensure effective 

reprocessing of RME. Improper reprocessing of RME may 

transmit pathogens to patients and affect the functionality of 

the equipment. VHA facilities are responsible for minimizing 

patient risk and maintaining a safe environment. The 

facility’s reprocessing areas are required to meet VHA, 

Association for the Advancement of Medical Instrumentation, 

OSHA, and the JC standards. 

We inspected the SPD, gastrointestinal unit, OR, 

hemodialysis, and cardiac catheterization reprocessing 

areas. We found that all areas were clean and that clean 

and dirty equipment were separated. In addition, we found 

that appropriate monitors for biological and chemical 

monitoring were in place and that SPD staff competencies 

and training were completed. 

VA requires that traffic in the SPD areas be restricted to 

authorized personnel and that appropriate personal 

protective equipment be donned prior to entering SPD 

reprocessing areas.2 We observed a Biomedical 

Engineering employee enter the decontamination area 

without proper personal protective equipment. SPD staff 

instructed the employee to don the appropriate personal 

protective equipment, and facility managers assured us the 

employee received additional education. Therefore, we 

made no recommendation for this finding. However, we 

identified the following areas that needed improvement. 

RME and Case Cart Cleaning Processes. VHA requires that 

staff clean RME according to manufacturers’ instructions.3 

We observed the cleaning of three pieces of RME that 

required low-level disinfection and determined that staff 

appropriately followed manufacturers’ instructions. We also 

observed the reprocessing of eight pieces of RME that 

required high-level disinfection or sterilization. SPD staff did 

2 VA Handbook 7176; Supply, Processing and Distribution (SPD) Operational Requirements; August 16, 2002. 3 VHA Directive 2009-031, Improving Safety in the Use of Reusable Medical Equipment through Standardization of 

Organizational Structure and Reprocessing Requirements, June 26, 2009. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Miami VA Healthcare System, Miami, FL 

not follow the manufacturers’ instructions for four of the eight 

pieces of RME. 

Additionally, we found that the surgical case cart washer had 

been out of service since November 2010. While we were 

onsite, SPD staff demonstrated the interim process for 

cleaning the surgical case cart. The demonstration did not 

include letting the detergent stand for 10 minutes, as 

required by the detergent manufacturer’s instructions, or 

cleaning the surgical case cart wheels, as required by local 

process. 

SOPs. VHA requires facilities to establish device-specific 

SOPs for reprocessing RME in accordance with the 

manufacturers’ instructions.4 We reviewed the SOPs and 

manufacturers’ instructions for six pieces of RME. We found 

that the SOPs for three of the six pieces of RME were not 

fully consistent with the manufacturers’ instructions. 

Flash Sterilization Competencies. VHA requires annual 

competency validation for staff who flash sterilize RME.5 We 

reviewed the competency folders for 10 OR employees and 

found that none had current competency validations for flash 

sterilization. 

Eyewash Station Appropriateness and Testing. OSHA 

requires that an eyewash station be available for immediate 

use in areas where employees could be exposed to 

injurious, corrosive chemicals. The American National 

Standards Institute requires that eyewash stations be 

checked weekly to assure proper functioning. We noted that 

there was a portable eyewash station within the immediate 

vicinity of the OR in an area where chemicals were used. 

However, based on the volume of water it could contain, this 

portable eyewash station did not meet the requirements for 

15-minute eye irrigation. In addition, we found that the 

eyewash station in the SPD decontamination area was not 

checked weekly. 

Air Quality. VA requires that airflow be carefully controlled to 

minimize the movement of microorganisms from areas 

where equipment is cleaned to areas where clean equipment 

is stored.6 Local policy requires monthly monitoring of the 

4 VHA Directive 2009-031. 

5 VHA Directive 2009-004, Use and Reprocessing of Reusable Medical Equipment (RME) in Veterans Health
 

Administration Facilities, February 9, 2009.
 6 VA Handbook 7176.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Miami VA Healthcare System, Miami, FL 

airflow in these areas. During tests conducted from 

March through August 2010, the facility identified that 

positive air pressures were not maintained in the 

gastrointestinal unit clean area. However, there was no 

evidence to show that corrective actions were taken during 

this 6-month period. In addition, we found that monitoring of 

airflow was not completed in the reprocessing areas in 

December 2010. 

Sterilizer Preventive Maintenance. VA requires that 

equipment sterilizers undergo preventive maintenance in 

accordance with manufacturers’ instructions.7 The facility 

has an electronic work order system to track and document 

completed equipment repairs and preventive maintenance. 

However, an EtO gas sterilizer8 was not entered into the 

system when it was placed into service on May 21, 2008. 

System records show that the sterilizer has undergone 

repairs; however, since the sterilizer was not set up in the 

system, the required preventative maintenance was not 

documented as completed. 

Facility Reporting. VHA requires that specific RME 

elements, including validation of initial and ongoing staff 

competencies, SOP compliance, infection control monitoring, 

and risk management activities, be reported quarterly to an 

executive-level committee.9 We found that RME reports 

were not provided to an executive-level committee. 

Recommendations	 6. We recommended that SPD staff clean RME according 

to manufacturers’ instructions and clean surgical case carts 

according to detergent manufacturer’s instructions and the 

interim local process. 

7. We recommended that SOPs be consistent with 

manufacturers’ instructions. 

8. We recommended that managers complete annual 

competency validations for employees who flash sterilize 

RME. 

7 VA Handbook 7176.
 8 An EtO gas sterilizer is an automatic device that sterilizes plastic, rubber, metal, or sensitive materials using the
 

anti-bacteriologic agent ethylene oxide.

9 VHA Directive 2009-004.
 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Miami VA Healthcare System, Miami, FL 

9. We recommended that appropriate emergency eyewash 

stations are located in areas where chemicals are used and 

are tested weekly to ensure proper functioning. 

10. We recommended that airflow in the reprocessing areas 

be monitored and appropriately maintained. 

11. We recommended that processes be strengthened to 

ensure that sterilizers undergo preventive maintenance in 

accordance with manufacturers’ instructions. 

12. We recommended that specific RME elements be 

reported quarterly to an executive-level committee. 

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. 

Moderate Sedation. VHA requires providers to document a 

complete history and physical within 30 days of a procedure 

requiring moderate sedation and to re-evaluate the patient 

immediately prior to sedation.10 These evaluations must 

include a review of drug allergies. We reviewed the medical 

records of 10 patients who received moderate sedation and 

found that 2 records did not contain drug allergy 

assessments. 

Resuscitation Event Outcomes. VHA requires that facilities 

have a CPR Committee that reviews each resuscitation 

event and that specific elements, such as delays in CPR, be 

collected and reviewed for trends.11 We found that while 

individual events were evaluated, results were not reported 

to the committee. We also found that data on delays in 

initiating CPR were not collected. 

Medical Record Reviews. VHA requires that medical record 

reviews include monitoring for inappropriate use of the copy 

10 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 11 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 8 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Recommendations 

RN Competencies 

Recommendation 

Management of 

Workplace 

Violence 

and paste functions.12 We found that only Primary Care 

Service monitored for inappropriate use of the copy and 

paste functions. 

13. We recommended that processes be strengthened to 

ensure that drug allergy assessments are documented prior 

to procedures requiring moderate sedation and that 

compliance is monitored. 

14. We recommended processes be strengthened to ensure 

that all required resuscitation event elements are collected 

and that the CPR Committee reviews all resuscitation event 

evaluations. 

15. We recommended that medical record review processes 

be strengthened to ensure that inappropriate use of the copy 

and paste functions is monitored. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies and processes, interviewed 

nurse managers, and reviewed initial and ongoing 

competency assessment and validation documents for 

12 RNs. We identified the following area that needed 

improvement. 

Competency Validation Methods. The JC requires facilities 

to specify the assessment methods used (such as test 

taking, demonstration, or simulation) to determine an 

individual’s competency in required skills. We found that 

validation methods were not consistently specified in 5 of the 

12 competency folders reviewed. 

16. We recommended that competency validation methods 

be documented for required skills. 

The purpose of this review was to determine whether the 

facility issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

We reviewed the facility’s policy and training plan. We 

selected three assaults that occurred at the facility within the 

past 2 years, discussed them with managers, and reviewed 

12 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Miami VA Healthcare System, Miami, FL 

applicable documents. We identified the following area that 

needed improvement. 

Management of Incident. VHA policy requires that all violent 

incidents involving employee victims be discussed at the 

facility’s ARB.13 We reviewed ARB meeting minutes for 

FY 2010 and for FY 2011 through February 2011 and did not 

find documentation of discussion of an incident in which a 

patient assaulted an employee. 

Recommendation	 17. We recommended that processes be strengthened to 

ensure that all violent incidents involving employee victims 

are discussed at the ARB. 

Review Activities Without Recommendations
 

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

Care facility managed advance care planning and advance 

directives in accordance with applicable requirements. 

We reviewed 20 patients’ medical records and the facility’s 

advance care planning policy and determined that the facility 

generally met VHA requirements. We made no 

recommendations. 

EN Safety	 The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. While conducting the EOC 

review, we also inspected areas where EN products were 

stored, and we interviewed key employees. We determined 

that the facility generally met EN safety requirements. 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 medications, in accordance with applicable 

requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology outpatient clinic, and we 

interviewed employees. We determined that the facility 

13 VHA Handbook 7701.01, Occupational Safety and Health (OSH) Program Procedures, August 24, 2010. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Miami VA Healthcare System, Miami, FL 

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. 

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 17–25, 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 11 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Appendix A 

Facility Profile14 

Type of Organization Tertiary care medical center 

Complexity Level 1b 

VISN 8 

Community Based Outpatient Clinics Coral Springs, FL 

Deerfield Beach, FL 

Hollywood, FL 

Homestead, FL 

Key Largo, FL 

Key West, FL 

Miami, FL 

Sunrise, FL 

Veteran Population in Catchment Area 285,000 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

444 

 Community Living Center/Nursing 

Home Care Unit 

110 

 Other 118 domiciliary 

Medical School Affiliation(s) University of Miami Miller School of 

Medicine 

 Number of Residents 158 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

January 2011) 

$416 

Prior FY (2010) 

$425 

 Medical Care Expenditures $155 $459 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Hospital 

2,627 

39,954 

14,778 

2,640 

54,951 

40,621 

o Psychosocial Residential 

Rehabilitation Treatment Program 

5,124 6,439 

o Community Living Center/Nursing 

Home Care Unit 

5,416 31,579 

Hospital Discharges 2,301 6,450 

Total Average Daily Census (including all bed 

types) 

206 240 

Cumulative Occupancy Rate (in percent) 54 57 

Outpatient Visits 249,267 730,820 

14 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Reinstitute the PI Council, and implement 

proposed changes to the Leadership Council 

to improve the coordination of system-wide 

PI activities. 

The governance framework changed in 

January 2011. The PI Council was 

absorbed by the Performance 

Committee Executive Leadership 

Board, and PI information is reported 

directly to them. Local policy has been 

modified to reflect these changes. 

Y N 

2. Fully implement the policy for evaluation 

and disclosure of adverse events and track 

compliance with VHA policy. 

The disclosure policy and the clinical 

disclosure note title and template 

remain active in the computerized 

medical record. There has been an 

increase in the use of the clinical 

disclosure process since 2007. The 

Chief of Staff and the Preventive Ethics 

Coordinator provided disclosure 

refresher education. Disclosure 

reports are aggregated quarterly and 

reported to the Medical Executive 

Committee monthly. 

Y N 

EOC 

3. Conduct and document patient monitoring 

every hour on the locked MH unit in 

accordance with the risk abatement plan. 

Nursing staff conduct and document 

patient monitoring every hour on the 

locked MH unit. 

Y N 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

4. Maintain the security of confidential patient 

information. 

The Information Security Officer and 

Privacy Officer assess patient care 

areas on a weekly basis through EOC 

rounds. Reports are sent to area 

managers, and corrective actions are 

implemented when opportunities for 

improvement are identified. 

Information is reported to the EOC 

Safety Committee. 

N Y (see pages 4 

and 5) 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Miami VA Healthcare System, Miami, FL 

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 59.1 57.1 66.4 63.0 56.3 50.0 54.0 55.0 

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. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Hospital Outcome of Care Measures
 Hospital Outcome of Care Measures show what happened after patients with certain 

conditions15 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 12.70 7.56 14.43 19.97 21.19 16.70 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

15 Congestive heart failure is a weakening of the heart’s pumping power. With heart failure, your body does not get 

enough oxygen and nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens 

when blood flow to a section of the heart muscle becomes blocked, and the blood supply is slowed or stopped. If 

the blood flow is not restored in a timely manner, the heart muscle becomes damaged from lack of oxygen. 

Pneumonia is a serious lung infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, 

and fatigue. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 June 30, 2011 

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

Subject:	 CAP Review of the Miami VA Healthcare System, 

Miami, FL 

To:	 Associate Director, Bay Pines Healthcare Inspections 

Division (54SP) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

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

the report of the Combined Assessment Program Review of the Miami 

VA Healthcare System, Miami, Florida. 

2.	 Corrective action plans have been established with planned completion 

dates, as detailed in the attached report. 

Nevin M. Weaver, FACHE 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 29, 2011 

From: Director, Miami VA Healthcare System (546/00) 

Subject: CAP Review 

Miami, FL 

of the Miami VA Healthcare System, 

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

1.	 We thank you for allowing us the opportunity to review and respond to 

the subject report. 

2.	 We concur with the conclusions and recommendations presented by 

the Office of the Inspector General. We present you with the plans of 

action designed to correct those areas for which recommendations 

were provided. 

Mary D. Berrocal 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Miami VA Healthcare System, Miami, FL 

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 

all LSC deficiencies are assessed, ILSM plans are developed as needed, and 

appropriate staff education is provided to ensure fire safety. 

Concur 

Target date for completion: December 31, 2011 

The Facilities/Engineering Service and the COTR will design a validation tool to ensure 

that at the start of any project or construction an assessment is made to determine the 

need for ILSM. In addition, ILSM assessments will be conducted when any facility 

deficiency is found during EOC rounds or by any other means. Safety Section and P&A 

staff will work together to ascertain and implement appropriate ILSM, and post at the 

entrances of construction sites/areas. A current ILSM inventory will continue to be 

enforced by the Occupational Health and Safety Specialist and reported to the 

EOC-Safety Committee on a monthly basis and the Administrative Executive Board on 

a quarterly basis. Specifically for the Mental Health (MH) unit, the ILSM plan will include 

the following: (1) ensure free and unobstructed exits (2) no smoking policy enforced 

(3) enforced the housekeeping procedures to ensure a safe work environment during 

the project (4) to increase hazard surveillance (5) staff training (6) Increase hazard 

surveillance by organizational-wide educational programs. Training will be conducted 

1 day per month with two sessions during the next 6 months. 

Recommendation 2. We recommended that a comprehensive EOC inspection of the 

facility be conducted and that appropriate actions be taken to correct cleanliness 

deficiencies. 

Concur 

Target date for completion: August 1, 2011 

During the OIG inspection the vents and debris identified in the patient care areas, 

common areas, and others were cleaned on the spot. These areas are covered under 

the daily schedule for sanitation cleaning which includes disinfecting floors by wet 

mopping; dry mopping, horizontal/ vertical dusting, restroom care, and other duties. 

Also, there is a separate floor maintenance schedule which includes more intense 

scrubbing and stripping of floors every 90 days. All vents were cleaned by 

April 13, 2011. In addition to participation in organizational EOC inspections the EMS 

Supervisors are now required to perform a minimum of two inspections on a weekly 

basis. Areas identified as needing more cleaning are followed-up by the supervisor for 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Miami VA Healthcare System, Miami, FL 

completion. An EMS-Floor Care Coordinator has been identified to communicate with 

nursing service and will perform consistent rounds for the maintenance of floors 

throughout patient care areas and other critical areas. The Chief, EMS participates in 

weekly EOC rounds where deficiencies are identified and followed through with 

supervisors. During these rounds, tracking and trending analysis on sanitation issues 

are reported through the EOC-Safety Committee. 

Recommendation 3. We recommended that annual blood borne pathogens training 

and N95 respirator fit testing be completed and that compliance be monitored. 

Concur 

Target date for completion: (a) September 28, 2011; (b) January 2012 

The Employee Education Office will produce quarterly compliance reports for annual 

blood borne pathogen training and submit those to the respective Service Chiefs with a 

copy to Infection Control and to the Executive Leadership as appropriate. 

In order to improve the current process for N95 respirator fit testing, the following 

initiatives are being implemented: (1) categorize the fit testing program by 

service/binder (2) update the employee list by service with current employee information 

and fit testing date and (3) consolidate the respiratory fit testing program with other 

required employee annual health checks, i.e. PPD in collaboration with Safety, Human 

Resources, Infection Control, and IRMS to have a systematic process for these 

programs. 

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

clean and dirty supplies are stored separately. 

Concur 

Target date for completion: September 28, 2011. 

Monitoring of separation of clean and dirty equipment will be incorporated into EOC 

rounds and RME tracers as of August 29, 2011 and reinforced with EOC rounds 

members. Documentation of findings will be added to the EOC rounds check sheet. 

Education and corrective interventions are provided on-site as deficiencies are 

identified. Education on separation of clean and dirty has been scheduled in 

conjunction with blood borne pathogen training to be completed by 

September 28, 2011. 

Recommendation 5. We recommended that processes be strengthened to ensure that 

computers are locked when not attended. 

Concur 

Target date for completion: Completed July 5, 2011. Recommend closure. 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Miami VA Healthcare System, Miami, FL 

The training program on Information Security has been reinforced by offering bi-weekly 

classes to new employees. As of today 97 percent of all MVAHS employees have been 

trained. In addition, Information Security Officers (ISOs) will now participate in EOC 

rounds to identify security/confidentiality issues among employees with their personal 

computers. Some corrective measures include having ISOs implementing corrective 

measures during the rounds to address any discrepancies. Also, there was a security 

feature added to all personal computers where they are locked automatically every 

15 minutes. Additionally, a violation notice and computer access termination process 

has been instituted. When information security violations are identified the ISO will 

issue a hardcopy Information Security Violations Notice to the employee and their 

supervisor. After the second violation has been identified computer access will be 

terminated. Access may only be regained after additional training and 

Supervisor/Service Chief approval. 

Recommendation 6. We recommended that SPD staff clean RME according to 

manufacturers’ instructions and clean surgical case carts according to detergent 

manufacturer’s instructions and interim local process. 

Concur 

Target date for completion: Training Completed June 28, 2011. Recommend closure. 

Miami VA recognizes the importance of strict adherence to manufacturer’s guidelines 

for reprocessing of all RME. A continuous process of education and re-education has 

been in place and further strengthened with the goal of eliminating any deviation from 

manufacturer’s recommendations, to include minimizing potential human error. If any 

deviations are identified, a thorough fact-finding is conducted and timely appropriate 

actions/interventions are implemented to promptly address the findings. Miami VA has 

developed a procedure for cleaning the case carts and all staff has been educated on 

the process. Of the 20 people who work in the area in Miami, 19 have been trained and 

1 is on extended military leave. In addition, Miami has identified savings in SPD budget 

and will utilize funding to replace the cart washer. We anticipate replacement of the cart 

washer by February 2012. 

Recommendation 7. We recommended that SOPs be consistent with manufacturers’ 

instructions. 

Concur 

Target date for completion: September 16, 2011 

The current established process of the review of the SOP documentation has been 

strengthened to ensure that all SOPs adhere strictly to manufacturer’s 

recommendations. The cited SOPs were revised verbatim to the manufacturer’s 

language and are currently in the review process. All SOPs will go through the RME 

Committee for review. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Recommendation 8. We recommended that managers complete annual competency 

validations for employees who flash sterilize RME. 

Concur 

Target date for completion: Completed May 31, 2011. Recommend closure. 

All staff that performs flash sterilization completed a competency addendum in 

May 2011. 

Recommendation 9. We recommended that appropriate emergency eyewash stations 

are located in areas where chemicals are used and are tested weekly to ensure proper 

functioning. 

Concur 

Target date for completion: Completed. Recommend closure. 

In the temporary OR there is a portable eye wash station in use, but based on the 

volume it did not meet the required 15 minutes of eye irrigation. The Safety Department 

has increased the number of bottles for eye irrigation to meet with standard requirement 

of 15 minutes. Eyewash stations are being tested weekly in SPD as recommended. A 

tracking mechanism has been implemented to document testing. 

Recommendation 10. We recommended that airflow in the reprocessing areas be 

monitored and appropriately maintained. 

Concur 

Target date for completion: July 30, 2011. 

A process of notification of staff in the area any time pressure is out of range will be 

developed. The area is monitored 24 hrs, 7 days a week by a SIEMENS pressure 

differential monitor. 

In addition the facility is constructing a new reprocessing room (A712) with an expected 

completion date of September 30, 2011. The new utilities/equipment (new exhaust 

system, new differential pressure monitors, and the new temperature/relative humidity 

sensors) will be entered into the Equipment Inventory List and preventive maintenance 

on this equipment shall be done per manufacturers’ specifications. 

Recommendation 11. We recommended that processes be strengthened to ensure 

that sterilizers undergo preventive maintenance in accordance with manufacturers’ 

instructions. 

Concur 

Target date for completion: Completed April 15, 2011. Recommend closure. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the Miami VA Healthcare System, Miami, FL 

All sterilizers are being serviced in accordance with manufacturer’s specification. The 

electronic equipment record for one of the model 3017 EtO sterilizers, EE# 61602, was 

not complete. It has been corrected. 

Recommendation 12. We recommended that specific RME elements be reported 

quarterly to an executive-level committee. 

Concur 

Target date for completion: July 31, 2011 

Our process of reporting RME elements to an executive level committee was revised 

and fully implemented since January 2011. In order to improve the current process a 

quarterly monitoring of the process has been established by the Medical Executive 

Board. The MEB will include this specific RME monitor in its report to the PCELB on a 

quarterly basis. 

Recommendation 13. We recommended that processes be strengthened to ensure 

that drug allergy assessments are documented prior to procedures requiring moderate 

sedation and that compliance is monitored. 

Concur 

Target date for completion: August 30, 2011 

The Chief of Surgery and Chair of the Operative and Invasive Committee discussed and 

agreed the "Pre-Invasive Assessment" note template will be adjusted to include 

allergies. The attending doctors will be inputting the allergy information into the note. 

We collaborated with Informatics, who are making a tutorial (completed by 7/1/11) to 

educate the doctors on how to pull the allergies into the note most efficiently. The 

allergies listed in the patients’ chart will automatically be populated into the note. We 

will also be making copies of this tutorial and post them by the computers as a reminder 

to include the allergies (with the instructions). The COS will send this tutorial to 

providers hospital wide. We collaborated with IRMS and submitted a "footprint" request 

to adjust the template to automatically include the allergies. Expected completion on 

this is by 8/5/11. A forced field will be added to the template: an area addressing 

"previous reactions" to past anesthesia either with a "no,” or "yes" with an area to 

explain the reaction/problem. The surgical QM specialist will monitor OR/moderate 

sedation areas looking at various attending doctors notes monthly for compliance. An 

update to these process/findings will be discussed at the monthly Operative and 

Invasive Committee meeting. 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Recommendation 14. We recommended processes be strengthened to ensure that all 

required resuscitation event elements are collected and that the CPR Committee 

reviews all resuscitation event evaluations. 

Concur 

Target date for completion: Completed. Recommend closure. 

The completion of the Cardiopulmonary Resuscitation Monitoring sheet was 

strengthened by collaboration between nursing and the QM representative to the CPR 

Committee. A new process is that the QM representative contacts the person who 

completed the code monitoring sheet and requests that any missing elements be 

completed within 7 days. The VISN reporting format was adopted which identifies any 

delays in initiating CPR through procedure issues. Any outliers are reported monthly to 

the CPR committee. Under the strengthened process, the Chair of the CPR Committee 

performs an in depth review of all resuscitation events and reports his findings and 

recommendations monthly to the CPR Committee. 

Recommendation 15. We recommended that medical record review processes be 

strengthened to ensure that inappropriate use of the copy and paste functions is 

monitored. 

Concur 

Target date for completion: October 1, 2011 

The following processes to strengthen reporting of copy and paste monitoring are being 

implemented: 

(1) The Coding Section will report inpatient and outpatient copy and paste monitors 

(including eight defined elements) on an ongoing basis at the Medical Records 

Committee. 

(2) Clinical Services have been asked to incorporate copy and paste monitoring into 

their service specific reviews and where instances are found of copy and paste they will 

review the eight defined elements identified. 

(3) The facility Copy and Paste Policy was approved and published May 18, 2011. 

Recommendation 16. We recommended that competency validation methods be 

documented for required skills. 

Concur 

Target date for completion: October 1, 2011 

The Nursing Competency forms are being modified to include a column to specifically 

document (circle) the assessment/validation method being used to assess the 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the Miami VA Healthcare System, Miami, FL 

competency/skill. The new forms will be rolled out October 1, 2011 (commencing the 

new FY proficiency /evaluation cycle). This OIG finding and form modification will be 

presented to the Nursing Executive Council (NEC) on Wednesday, July 13, 2011. 

Recommendation 17. We recommended that processes be strengthened to ensure 

that all violent incidents involving employee victims are discussed at the ARB. 

Concur 

Target date for completion: July 29, 2011 

MVAHS is in the process of reviewing and implementing a new Accident Review Board 

(ARB) with a charter/policy to ensure appropriate personnel are members of the ARB. 

The ARB Committee will meet monthly and report to the Administrative Executive Board 

(AEB). One of the responsibilities of the ARB is to anonymously discuss all employee 

accidents/incidents in order to ensure the health and safety of all employees. The ARB 

will focus on employee’s incident/accident and look for causation, proper coding, 

prevention and, accident/mishap investigation. 

VA OIG Office of Healthcare Inspections 25 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Contributors Carol Torczon, ACNP, Project Leader 

Darlene Conde`-Nadeau, NP, Team Leader 

David Griffith, RN 

Karen McGoff-Yost, LCSW 

Clarissa Reynolds, MBA 

Annette Robinson, RN 

Christa Sisterhen, MCD 

Toni Woodard 

David Spilker, Resident Agent in Charge, Office of Investigations 

VA OIG Office of Healthcare Inspections 26 
CAP Review of the Miami VA Healthcare System, Miami, FL 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Sunshine Healthcare Network (10N8) 

Director, Miami VA Healthcare System (546/00) 

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 

U.S. Senate: Bill Nelson, Marco Rubio 

U.S. House of Representatives: Ileana Ros-Lehtinen 

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

VA OIG Office of Healthcare Inspections 27