Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No.10-02992-83 

Combined Assessment Program
 

Review of the
 

Bay Pines VA Healthcare System
 

Bay Pines, Florida
 

February 8, 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 Bay Pines VA Healthcare System, Bay Pines, FL 

Glossary 

AD advance directive 

AED automated external defibrillator 

BCLS Basic Cardiac Life Support 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CPR cardiopulmonary resuscitation 

CPRS computerized patient record system 

EOC environment of care 

FTE full-time employee equivalents 

FY fiscal year 

IC infection control 

JC Joint Commission 

LMS Learning Management System 

MDRO multidrug-resistant organisms 

MSDS material safety data sheets 

MSEB Medical Staff Executive Board 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PR peer review 

QM quality management 

SOPs standard operating procedures 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, 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
 

QM..................................................................................................................... 2
 

EOC................................................................................................................... 4
 

COC .................................................................................................................. 5
 

Management of Test Results............................................................................. 5
 

Review Activities Without Recommendations ......................................................... 6
 

Management of MDRO...................................................................................... 6
 

Medication Management ................................................................................... 6
 

Physician C&P................................................................................................... 6
 

Comments................................................................................................................... 7
 

Appendixes 

A. Facility Profile .................................................................................................... 8
 

B. Follow-Up on Previous Recommendations........................................................ 9
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 12
 

D. VISN Director Comments .................................................................................. 14
 

E. Facility Director Comments ............................................................................... 15
 

F. OIG Contact and Staff Acknowledgments ......................................................... 20
 

G. Report Distribution ............................................................................................ 21
 

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

Review of the Bay Pines VA Healthcare System, 

Bay Pines, 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 

November 15, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

	 Management of Multidrug-Resistant 

Organisms 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

The facility’s reported accomplishment 

was the culture change in the 

community living center to an 

environment that encourages respect, 

relationships, and a sense of belonging. 

Recommendations: We made 

recommendations in the following four 

activities: 

Quality Management: Evaluate 

resuscitation events for errors, and 

analyze data for trends and 

opportunities to improve care. 

Document that all peer review corrective 

actions have been completed, and 

provide a summary of completed actions 

to the oversight committee. Aggregate 

and analyze service-specific data 

related to unexpected events in 

conjunction with moderate sedation. 

Strengthen medical record review 

processes to ensure that all required 

components are monitored, and report 

results to the oversight committee. 

Environment of Care: Provide training to 

staff regarding access to material safety 

data sheet information. Ensure that 

designated staff complete annual 

respirator fit testing. Require radiology 

department staff to have documented 

annual radiation safety training. 

Coordination of Care: Update the local 

policy, and require designated staff to 

document advance directive notification 

and screening for all patients. 

Management of Test Results: 

Communicate normal test results to 

patients within the specified timeframe. 

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.

 (original signed by:) 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, 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 seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through November 19, 2010, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

CAP review of the facility (Combined Assessment Program 

Review of the Bay Pines VA Healthcare System, Bay Pines, 

Florida, Report No. 07-01248-13, October 24, 2007). The 

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

facility had corrected all findings. (See Appendix B for 

further details.) 

During this review, we also presented crime awareness 

briefings for 245 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 

The Bay View CLC has worked to develop relationships with 

residents to demonstrate respect and encourage a sense of 

belonging. Residents share in decision making through 

neighborhood meetings and participation in the IC 

Committee. Examples of resident driven projects include the 

garden club, the renovation of surroundings to a beach 

décor, participation in computer games to develop 

relationships, and the transformation of a traditional food 

service to a select menu prepared by chefs. 

CLC Culture 

Change 

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. 

Review of Resuscitation and Its Outcomes. VHA and The 

JC require that facilities evaluate each resuscitation event for 

opportunities to evaluate and implement desired changes.1 

The CPR Committee had started to compile data on each 

event, but we did not find evidence that they discussed the 

results and made recommendations to improve processes. 

1 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 2 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

For example, data revealed potential problems with 

timeliness of intubation, epinephrine administration, and 

defibrillation, but meeting minutes did not document 

discussion or actions taken. 

PR. Facility policy requires service chiefs to discuss PR 

findings with individual providers and to implement any 

actions recommended by the PR Committee. Service chiefs 

are then required to provide written feedback to the PR 

Committee that recommended actions were completed. We 

found that service chiefs were not providing the PR 

Committee with written feedback of completed actions. In 

addition, the PR Committee’s quarterly report to the MSEB 

did not include the facility required summary of actions 

completed by service. 

Moderate Sedation. VHA requires facilities to monitor and 

analyze moderate sedation, including the use of reversal 

agents.2 We did not find evidence that the Operative and 

Invasive Procedure Committee critically analyzed data 

related to the use of reversal agents and other unexpected 

events in conjunction with moderate sedation. The facility 

needs to aggregate service-specific data to identify possible 

organization-wide trends. 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include specific areas of review 

and to monitor the copy and paste functions.3 While services 

had completed medical record quality reviews, we found that 

they did not include all of the required components. For 

example, we found that only one service monitored the copy 

and paste functions in the electronic medical record. In 

addition, results of service-specific quality reviews were not 

reported to the Medical Record Committee for trending, 

analysis, and identification of opportunities for improvement. 

Recommendations	 1. We recommended that the CPR Committee evaluate 

each resuscitation event for errors or deficiencies in 

technique and critically analyze that data to identify trends 

and opportunities to improve care. 

2. We recommended that service chiefs provide the PR 

Committee with written documentation that all corrective 

actions have been completed and that the PR Committee 

2 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 3 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

EOC
 

Recommendations 

include a summary of completed actions in quarterly reports 

to the MSEB. 

3. We recommended that service-specific data related to 

unexpected events, including the use of reversal agents, in 

conjunction with moderate sedation be aggregated and 

analyzed. 

4. We recommended that medical record review processes 

be strengthened to ensure that each service monitors all 

required components, including the copy and paste 

functions, and that results be reported to the Medical Record 

Committee. 

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 inpatient units (locked behavioral health, 

medical, surgical, CLC, and medical intensive care), the 

emergency department, radiology, and outpatient clinics. The 

facility maintained a generally clean and safe environment. 

However, we identified the following conditions that needed 

improvement. 

MSDS. OSHA requires that MSDS information be available 

in each clinical area. Staff on three of six units could not 

locate paper MSDS copies and were not aware of the 

electronic MSDS program, so they could not access the 

information. 

IC. OSHA requires that designated employees be fit tested 

annually if the facility uses N95 respirators. We reviewed 

annual training records for employees designated to use the 

respirators and found that 14 (56 percent) of the 25 records 

did not have documentation of the required annual fit testing. 

Radiation Safety. The Nuclear Regulatory Commission 

requires annual radiation safety training for radiology 

department employees. We reviewed training records for 

five radiology registered nurses and five technologists. None 

of the records had complete documentation of radiation 

safety training. 

5. We recommended that managers provide training to 

staff regarding access to MSDS information. 

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

COC 

Recommendation 

Management of 

Test Results 

6. We recommended that designated staff complete annual 

N95 respirator fit testing. 

7. We recommended that radiology department staff have 

documented annual radiation safety training. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning, ADs, and 

discharges in accordance with applicable requirements. 

We reviewed medical records for documentation of advance 

care planning, ADs, and discharge instructions. We 

identified the following area that needed improvement. 

Documentation of AD Notification and Screening. VHA 

requires that facility directors identify staff responsible for 

conducting AD notification and screening and that AD 

notification and screening are documented in each patient’s 

medical record.4 We reviewed the medical records of 

12 patients. We found no documentation of AD notifications, 

and 11 (92 percent) of the records did not have evidence of 

AD screening. In addition, facility policy did not assign 

designated staff to complete AD notification and screening. 

8. We recommended that managers update facility policy 

and require that designated staff document AD notification 

and screening for all patients. 

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.5 

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

reviewed medical records. We identified the following area 

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 results were available to 

the ordering provider.6 We reviewed the medical records of 

20 patients who had normal results and found that 

4 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 5 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

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

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

6 (30 percent) records did not contain documented evidence 

that facility staff communicated results to the patients. 

Recommendation	 9. We recommended that staff communicate normal test 

results to patients within the specified timeframe. 

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 an 

inpatient medical/surgical unit and a CLC unit 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, 

transportation, and administration of hazardous medications, 

specifically chemotherapy, in accordance with applicable 

requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the pharmacy and the chemotherapy clinic. 

We also interviewed staff. 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 6 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

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 14–19, 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 7 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

Appendix A 

Facility Profile7 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 8 

CBOCs Bradenton, FL 

Fort Myers, FL 

Naples, FL 

Palm Harbor, FL 

Port Charlotte, FL 

Sarasota, FL 

Sebring, FL 

St. Petersburg, FL 

Veteran Population in Catchment Area 320,648 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

226 

 CLC/Nursing Home Care Unit 112 

 Other 66 domiciliary 

Medical School Affiliation(s) University of South Florida 

Nova Southeastern University 

 Number of Residents 41.9 

FY 2010 Prior FY 

Resources (in millions): 

 Total Medical Care Budget $607 $556 

 Medical Care Expenditures $606 $556 

Total Medical Care FTE 3,235 3,256 

Workload: 

 Number of Station Level Unique 

Patients 

97,375 95,010 

 Inpatient Days of Care: 

o Acute Care 63,790 54,888 

o CLC/Nursing Home Care Unit 31,499 30,453 

Hospital Discharges 12,956 12,069 

Total Average Daily Census (including all bed 

types) 

353 324 

Cumulative Occupancy Rate 87.6 77.4 

Outpatient Visits 1,263,477 1,207,967 

7 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Protect health information from 

unauthorized disclosure. 

(Nursing Service Monitoring Program) 

Question #1: Unattended computers in 

your work area are secure = 

97.8 percent compliance. Question #2: 

Sensitive paper documents secure or 

transmitted/discarded securely = 

98.6 percent compliance. 

Y N 

2. Properly place ceiling tiles in tracks, and 

replace damaged and stained ceiling tiles. 

All ceiling tiles identified in the report 

were immediately replaced, and those 

not properly aligned were placed into 

the correct position. 

Environmental Management Services 

has staff to systematically assess each 

building for damaged, stained, or 

improperly placed ceiling tiles. 

Supervisors conduct monthly 

inspections to identify discrepancies 

and take corrective action if needed. 

Y N 

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

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

3. Address residue on walls near sinks, All soiled surfaces were cleaned, and Y N 

compromised surfaces on patient furniture any adhesive residue was removed. 

and equipment, and stained privacy curtains. Unsafe furniture was removed from 

use, and replacements were ordered. 

The torn seat cushion in the patient 

shower and the stained privacy 

curtains in the patient care area were 

immediately replaced. Fifty patient bed 

trays were ordered and have been 

installed. All patient bedside night 

stands identified for replacement have 

been replaced. Privacy curtains are 

routinely changed. Monitoring the 

condition of furniture and privacy 

curtains in patient care areas is done 

by Environmental Management 

Services supervisors during monthly 

inspections. 

CPRS Business Rules 

4. Ensure CPRS business rules comply with 

VHA policy related to altering signed notes 

in the medical record. 

This issue was addressed and 

resolved prior to the OIG exit. Health 

Information Management Systems staff 

removed this business rule and 

restricted the ability to retract, amend, 

or delete signed medical records to the 

Privacy Officer and the Chief of Health 

Information Management Systems. 

Y N 

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

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

CBOC 

5. Ensure clinical staff performing direct 

patient care comply with VHA policy related to 

maintenance of CPR certification. 

Facility policy and medical staff bylaws 

and rules were amended to ensure 

compliance with VHA policy. CPR 

competence is a requirement for all 

physicians. Newly hired physicians 

receive CPR and AED education. All 

physicians must maintain current active 

BCLS certification. 

Service chiefs and supervisors ensure 

designated staff are trained and 

maintain current certification in BCLS. 

Employees must ensure BCLS cards 

are current. Basic Life Support training 

uses American Heart Association 

guidelines and covers AED use. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, 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 

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 63.2 67.4 64.2 58.9 58.5 58.8 

VISN 65.8 68.3 64.3 58.1 56.8 56.5 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

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 12 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

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

conditions received hospital care.8 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 CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 14.76 10.3 16.52 19.96 22.2 15.26 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

8 CHF 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 13 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, FL 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 20, 2011 

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

Subject: CAP Review of the Bay Pines VA Healthcare System, 

Bay Pines, FL 

To: Director, 

(54KC) 

Kansas City Healthcare Inspections Division 

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

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

the report of the Combined Assessment Program Review of the Bay 

Pines VA Healthcare System, Bay Pines, Florida. 

2.	 Corrective action plans have been established with planned completion 

dates, as detailed in the attached report. 

Nevin M. Weaver, FACHE
 

Network Director, VISN 8
 

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

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 January 19, 2011 

From:	 Director, Bay Pines VA Healthcare System (516/00) 

Subject:	 CAP Review of the Bay Pines VA Healthcare System, 

Bay Pines, FL 

To:	 Director, VISN 8 (10N8) 

1.	 The recommendations made during the Office of Inspector General 

(OIG) Combined Assessment Program (CAP) Review conducted 

November 15–November 19, 2010, have been reviewed and our 

comments and implementation plan are noted below. 

2.	 I would like to thank the OIG CAP Review Team for their 

professionalism and consultative feedback to our employees during 

our review. This review provides us with the opportunity to continue 

improving care to our veterans. 

3.	 If you have questions or require additional information, please contact 

Joanna Eastman-Gaudreau, Risk Manager, at 727-398-9317. 

WALLACE M. HOPKINS, FACHE
 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, 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 the CPR Committee evaluate each 

resuscitation event for errors or deficiencies in technique and critically analyze that data 

to identify trends and opportunities to improve care. 

Concur 

Target Completion Date: March 31, 2011 

We had previously identified opportunities for improvement of code events such as 

documentation and additional training. We have revised the code data collection “code” 

sheet and implemented the use of an electronic pocket personal computer based 

system which records data entered at a code and allows for synchronization with 

defibrillator data which creates a more accurate event report. To facilitate tracking of all 

code events, we have also developed an electronic incident report tool to report these 

events. All code events are reviewed at the monthly CPR Committee. Each committee 

member is assigned a code event to review prior to the meeting and to present an 

overall summary of the code at the meeting. In collaboration with the primary area the 

opportunity to improve care will be initiated and tracked to completion. This new 

process allows the CPR Committee to evaluate each resuscitation event for errors or 

deficiencies in technique and critically analyze data to identify trends and opportunities 

to improve care. Summary reports containing performance improvement activities are 

prepared and presented to the Critical Care Committee quarterly. 

Recommendation 2. We recommended that service chiefs provide the PR Committee 

with written documentation that all corrective actions have been completed and that the 

PR Committee include a summary of completed actions in quarterly reports to the 

MSEB. 

Concur 

Target Completion Date: May 31, 2011 

A new process for documenting and monitoring PR Committee 

recommendations/corrective actions was developed and approved at the 

December 2010 PR Committee. The PR Committee/Chairman will send a 

memorandum to the Service Chief notifying them that their respective service provider 

was issued a Final Level 2 or Level 3 Rating which may contain 

recommendations/corrective actions for improvement in clinical care or services, as 

applicable. The Service Chief will confirm review and completion of the 

recommendations/corrective actions with the provider by returning written 

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

documentation (certification of completion) to the PR Committee. The PR Committee 

will monitor completion of these recommendations/corrective actions on a quarterly 

basis. The PR Committee will then provide a summary report to the MSEB verifying 

completion of the recommended corrective actions each quarter. The MSEB will 

document their review of this information in the MSEB minutes. This new process was 

initiated following the January 2011 PR Committee meeting. The first quarterly 

summary report to the MSEB will be for Quarter 2 and is scheduled for presentation at 

the regularly scheduled MSEB meeting in May 2011. 

Recommendation 3. We recommended that service-specific data related to 

unexpected events, including the use of reversal agents, in conjunction with moderate 

sedation be aggregated and analyzed. 

Concur 

Target Completion Date: February 28, 2011 

We have developed a dashboard for Operative and Other Invasive Procedures 

Committee that includes aggregate data from all clinical sections that use moderate 

sedation. Each section performing moderate sedation is expected to report the total 

number of cases and any adverse or unexpected events, including the use of reversal 

agents. This data will be aggregated, trended and analyzed by the section/service 

levels for discussion at the quarterly Operative and Other Invasive Procedures 

Committee. Our critical analysis of this data will be stratified at the section/service and 

overall healthcare system levels. Services have been educated on the revised process 

and full implementation is expected at the next quarterly Operative and Other Invasive 

Procedures Committee meeting in February 2011. 

Recommendation 4. We recommended that medical record review processes be 

strengthened to ensure that each service monitors all required components, including 

the copy and paste functions, and that results be reported to the Medical Record 

Committee. 

Concur 

Target Completion Date: March 31, 2011 

We have developed a new medical record review tool with all the required components, 

including the copy and paste functions, as identified in VHA Handbook 1907.01. Staff 

have been educated on the use of the tool and data is currently being retrieved from the 

medical record. Service specific data will be collected, aggregated, trended and 

analyzed by the Medical Records Subcommittee monthly, shared with service 

leadership, and reported to the Management of Information Committee for further 

actions/recommendations at the MSEB, as appropriate. 

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

Recommendation 5. We recommended that managers provide training to staff 

regarding access to MSDS information. 

Concur 

Target Completion Date: February 14, 2011 

Leadership has provided a myriad of educational opportunities to inform staff where to 

locate the MSDS reference material. Staff training was provided via an electronic 

postmaster message sent out to all staff on January 14, 2011, and at the Quarterly Fire 

and Safety Educational sessions conducted on January 7, 10, and 11, 2011. Future 

quarterly fire and safety educational sessions and bi-monthly New Employee 

Orientation will contain updated training elements on access to MSDS. Also, MSDS 

access information has been added to the inventory of screen savers that rotate over 

each employee’s computer work station at periodic intervals. Staff knowledge will be 

monitored during weekly Leadership/EOC Rounds. 

Recommendation 6. We recommended that designated staff complete annual N95 

respirator fit testing. 

Concur 

Target Completion Date: March 31, 2011 

The respirator used at the Bay Pines VA Healthcare System is the Half-mask dual 

cartridge respirator (N100) equipped with HEPA filters which provides additional 

protection in lieu of the N95. The supervisors of the employees who were identified as 

not compliant with annual fit testing during the OIG visit have been contacted to require 

the employees to obtain their medical clearance form and make an appointment with 

the Safety Office to have the fit testing activity completed no later than March 31, 2011. 

The IC Committee will charter a workgroup to conduct a risk assessment of the 

effectiveness of the current fit testing program and to identify the designated staff who 

requires annual fit testing. 

Recommendation 7. We recommended that radiology department staff have 

documented annual radiation safety training. 

Concur 

Target Completion Date: Completed 

Radiation Safety Training had been completed by all appropriate staff (radiation 

workers). However it was reported during the OIG visit, documentation of the 

completed training was not easily retrievable. To facilitate tracking completion of the 

training, radiation protection training has been added to the VA LMS for all appropriate 

staff. The employee, supervisor, and radiation safety officer are able to monitor 

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

radiation protection education through the LMS and LMS Administrator completion 

report. 

Recommendation 8. We recommended that managers update facility policy and 

require that designated staff document AD notification and screening for all patients. 

Concur 

Target Completion Date: Completed 

On Wednesday, November 17, 2010, all Social Work staff members received education 

regarding AD notification and screening. Additional information was added to the 

Advance Directive Discussion Note template to ensure the components of the note are 

in compliance with VHA Handbook 1004.02. In addition, the Bay Pines VA Health Care 

System Memorandum 516-10-16-013, Advance Directives, has also been updated to 

ensure compliance that designated staff document AD notification and screening for all 

patients. The Social Work Supervisor is monitoring a random sample daily for 

compliance which shows satisfactory results. 

Recommendation 9. We recommended that staff communicate normal test results to 

patients within the specified timeframe. 

Concur 

Target Completion Date: April 29, 2011 

Some services are currently reporting normal test results to patients within the 14-day 

time frame. However, several services are still in the process of collaborating with 

clinical application coordinators to create a CPRS Template that generates an Auto 

Letter to patients regarding their normal test results. This mechanism will also provide 

documentation in CPRS in the form of a progress note. Bay Pines VA Healthcare 

System Memorandum 516-10-11-069, Ordering and Reporting of Test Results, will be 

updated to reflect normal test results to be communicated to the patient within the 

14-day time frame. 

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

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Dorothy Duncan, Director 

Kansas City Office of Healthcare Inspections 

Contributors Reba B. Ransom, Team Leader 

Gail Bozzelli 

Sami O’Neil 

Noel Rees 

Laura Tovar 

Jennifer Whitehead 

Anthony Heddell, Office of Investigations 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Bay Pines VA Healthcare System, Bay Pines, 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, Bay Pines VA Healthcare System (516/00) 

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: Gus M. Bilirakis, Vern Buchanan, Kathy Castor, 

Connie Mack, Tom Rooney, C.W. Bill Young 

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

VA OIG Office of Healthcare Inspections 21