Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-01192-63 

Combined Assessment Program
 

Review of the
 

West Palm Beach VA Medical Center
 

West Palm Beach, Florida
 

January 18, 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 West Palm Beach VA Medical Center, West Palm Beach, FL 

Glossary 

ACLS Advanced Cardiac Life Support 

AD advance directive 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CLC community living center 

COC coordination of care 

CT computed tomography 

EOC environment of care 

ESA erythropoiesis-stimulating agent 

facility West Palm Beach VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FTE full-time employee equivalents 

FY fiscal year 

IC infection control 

JC Joint Commission 

MH mental health 

MR magnetic resonance 

MRI magnetic resonance imaging 

MRSA Methicillin-resistant Staphylococcus aureus 

NCPS National Center for Patient Safety 

NFPA National Fire Protection Association 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

OSHA Occupational Safety and Health Administration 

PI performance improvement 

PPE personal protective equipment 

QM quality management 

RME reusable medical equipment 

SOPs standard operating procedures 

SPD Supply, Processing, and Distribution 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Table of Contents 

Page
 

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

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

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

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

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

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

MRI Safety......................................................................................................... 2
 

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

QM..................................................................................................................... 6
 

Medication Management ................................................................................... 7
 

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

COC .................................................................................................................. 8
 

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

RME .................................................................................................................. 9
 

Suicide Prevention Safety Plans........................................................................ 10
 

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

Appendixes 

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

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

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 17
 

D. VISN Director Comments .................................................................................. 19
 

E. Facility Director Comments ............................................................................... 20
 

F. OIG Contact and Staff Acknowledgments ......................................................... 25
 

G. Report Distribution ............................................................................................ 26
 

VA OIG Office of Healthcare Inspections 
 

 

 

 

Executive Summary: Combined Assessment Program 

Review of the West Palm Beach VA Medical Center, 

West Palm Beach, 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 

September 20, 2010. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

	 Coordination of Care 

	 Physician Credentialing and 

Privileging 

	 Reusable Medical Equipment 

	 Suicide Prevention Safety Plans 

Recommendations: We made 

recommendations in the following four 

activities: 

Magnetic Resonance Imaging Safety: 

Security of the “mobile” magnetic 

resonance imaging (MRI) unit should be 

strengthened, and access to the 

Radiology Service MRI suite needs to 

be restricted. Equipment used in MRI

areas should be labeled as safe or

unsafe, and the MRI compatible 

ventilator should be properly cleaned 

and maintained. Staff should comply 

with local policy and the manufacturer’s 

guidelines when using the ferromagnetic 

detector, and emergency code drills 

should be conducted in MRI areas. 

Environment of Care: Nursing Service 

should be consistently represented at 

environment of care rounds, and fire 

drills need to be conducted in 

accordance with National Fire Protection 

Association requirements. Appropriate 

staff should receive required training on 

the identification of environmental 

hazards that pose a risk to suicidal 

patients. 

Quality Management: The facility needs 

to develop a process to track 

compliance with Advanced Cardiac Life 

Support training, and the Medical 

Record Committee needs to monitor the 

use of the copy and paste functions. 

Medication Management: Clinicians 

should consistently document all 

required influenza vaccination elements. 

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 Patricia Christ 

 Deputy Assistant Inspector General for 

Healthcare Inspections for:) 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Objectives and Scope 

Objectives
 

Scope
 

Objectives. 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. 

Scope. 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 eight activities: 

	 COC 

	 EOC 

	 Medication Management 

	 MRI Safety 

	 Physician C&P 

	 QM 

	 RME 

	 Suicide Prevention Safety Plans 

The review covered facility operations for FY 2009 and 

FY 2010 through September 20, 2010, 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 West Palm Beach VA Medical Center, West Palm Beach, FL 

CAP review of the facility (Combined Assessment Program 

Review of the West Palm Beach VA Medical Center, 

West Palm Beach, Florida, Report No. 08-01331-32, 

December 2, 2008). The facility had corrected all findings. 

During this review, we also presented crime awareness 

briefings to 192 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. 

Results 

Review Activities With Recommendations 

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

facility maintained a safe environment and safe practices in 

the MRI areas. Safe MRI procedures minimize risk to 

patients, visitors, and staff and are essential to quality patient 

care. 

We inspected both the “mobile” MRI unit (located in a 

permanent trailer) and the MRI area in Radiology Service. 

We examined medical and training records, reviewed 

relevant policies, and interviewed key personnel. We 

determined that the facility had developed adequate safety 

policies and had conducted a risk assessment of the 

environment, as required by JC. 

We found that patients in the magnet rooms were directly 

observed at all times. Two-way communication was 

available between the patient and the MRI technologist, and 

the patient had access to a push-button call system while in 

the scanner. 

We reviewed the medical records of 10 patients who had 

received an MRI for evidence of appropriate screening. All 

10 patients had been appropriately screened prior to their 

MRI, and the signed screening forms were scanned into their 

medical records. Contrast media was used for 5 of the 

10 MRIs; however, since none of the 5 patients were 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

considered high risk, signed informed consent prior to the 

procedure was not required. 

We reviewed the training records of 6 Radiology Service 

personnel and 10 support personnel who had access to MRI 

Zones III and IV1 for evidence of annual MRI safety training. 

We found that Radiology Service personnel received 

appropriate training. Support personnel received only the 

MRI safety training covered in annual mandatory training 

required for all facility staff. Police staff received MRI safety 

training for the first time just prior to our visit. Facility 

managers told us that members of emergency code teams 

would receive MRI safety training. Since all required staff 

had at least received the MRI safety training contained in the 

annual mandatory training module by the time we left site, 

we made no recommendation for this finding. However, we 

identified the following conditions that needed improvement. 

Safety. American College of Radiology guidelines require 

physical barriers to prevent unauthorized or uncontrolled 

access to Zones III and IV. We found that security of the 

“mobile” MRI unit, located in a trailer in the parking deck area 

adjacent to the facility, needed to be strengthened. 

Technicians are usually alone in the unlocked trailer with a 

patient. Unauthorized access to Zone IV could occur when 

the technician is assisting the patient in the magnet room. 

Equipment kept in the MRI area was not clearly marked “MR 

Safe,” “MR Conditional,” or “MR Unsafe,” posing a risk that 

unsafe equipment could inadvertently be introduced into the 

magnet room. We also found that the MRI compatible 

patient ventilator contained contaminated sterile supplies, 

used patient medications, unlocked medication/supply 

drawers, and “MR Unsafe” metal instruments. Although the 

ventilator belonged to MRI, it was used for other procedures 

and was not properly cleaned and maintained. 

The configuration of the MRI suite in Radiology Service was 

inconsistent with American College of Radiology guidance. 

Zones II and III were combined and shared with CT. Access 

to Zone III was not physically restricted to only trained MRI 

staff and screened MRI patients, as required. A curtain was 

1 Zone III is adjacent to the entrance to the magnet room (Zone IV). Access to both zones should be limited to 

screened patients and MRI staff. There should be physical barriers to prevent unauthorized access to these areas. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Recommendations 

EOC 

the only barrier between patients waiting for a CT scan and 

the entrance to the MRI magnet room (Zone IV). 

We also observed that MRI staff did not comply with their 

local MRI safety policy or the manufacturer’s guidelines for 

use of the ferromagnetic detector. Although local policy 

requires staff to remove certain items worn on their person 

before entering the magnet room and restricts anyone from 

entering the magnet room if the Ferralert® alarm has 

sounded, we observed staff entering while the alarm 

sounded. This condition was also identified in the risk 

assessment conducted in November 2009. 

With the exception of fire drills, emergency code drills (for 

medical, behavioral, and other types of emergencies) were 

not conducted in MRI areas. 

1. We recommended that security of the “mobile” MRI unit 

be strengthened. 

2. We recommended that equipment used in MRI areas be 

properly labeled as safe or unsafe and that the MRI 

compatible ventilator be properly cleaned and maintained 

after use to ensure that unsafe supplies are not left with the 

equipment. 

3. We recommended that a physical barrier be placed in the 

Radiology Service MRI suite to prevent unauthorized or 

accidental entry to Zones III and IV. 

4. We recommended that MRI staff comply with local policy 

and the manufacturer’s guidelines regarding use of the 

ferromagnetic detector. 

5. We recommended that emergency code drills be 

conducted in MRI areas. 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment. 

VHA facilities are required to establish a comprehensive 

EOC program that fully meets VHA, NCPS, OSHA, NFPA, 

and JC standards. 

We inspected the dialysis unit, the locked inpatient MH unit, 

two CLC units, the hospice unit, the intensive care unit, the 

emergency department, an inpatient medical unit, the 

telemetry unit, the dental clinic, three primary care/specialty 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

clinics, and the post-anesthesia care unit and found that the 

facility maintained a generally clean and safe environment. 

The IC program appropriately aggregated and analyzed 

hand hygiene data for PI. In addition, PI data was 

consistently reported to the IC Committee when trends or 

educational needs that required follow-up were identified. 

We determined that all selected employees from nursing, 

Radiology Service, and the bronchoscopy suite had received 

annual N952 fit testing for FY 2010, as required by OSHA. In 

addition, 27 (87 percent) of 31 selected employees from 

nursing, medicine, audiology and speech pathology, and 

Environmental Management Services had completed annual 

bloodborne pathogens training for FY 2009, as required by 

OSHA. 

The NFPA requires that oxygen tanks be properly secured 

and stored. We found an unsecured oxygen tank in the 

isolation room of the post-anesthesia care unit. Managers 

took immediate action to remove and properly secure the 

oxygen tank in a storage room. In addition, we found three 

unattended and unsecured carts stocked with dialysis 

chemicals on the dialysis unit. While we were onsite, 

managers removed the carts and placed them inside a 

storage room. Since these conditions were corrected while 

we were onsite, we made no recommendations for these 

findings. However, we identified the following conditions that 

needed improvement. 

Environmental Rounds. VHA policy3 requires that weekly 

EOC rounds led by the Director or Associate Director include 

participation by managers in nursing, building management, 

engineering, and safety; representatives from patient safety 

and IC; and others, as required. We reviewed attendance 

2nd records for EOC rounds conducted during the and 

3rd quarters of FY 2010 and found that Nursing Service was 

not consistently represented. 

Fire and Life Safety. The NFPA requires that fire drills be 

conducted once per shift per quarter in each building defined 

as health care occupancy. We reviewed fire drill records for 

4th 1st 2nd the quarter of FY 2009 and for the , , and 

2 A disposable particulate respirator that has the ability to filter out 95 percent of particles greater than 0.3 microns
 

in diameter.
 3 Deputy Under Secretary for Health for Operations and Management, “Environmental Rounds,” memorandum,
 

March 5, 2007.
 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

3rd quarters of FY 2010 and found that fire drills were not 

consistently conducted on all shifts. 

Training. VHA policy4 requires employees of locked MH 

units and members of the Multidisciplinary Safety Inspection 

Team to complete training on environmental hazards that 

represent a threat to suicidal patients. This training should 

occur initially during orientation and annually thereafter. We 

reviewed training records for FY 2009 and found that only 

5 (33 percent) of 15 selected employees from the locked 

inpatient MH unit and members of the Multidisciplinary 

Safety Inspection Team had documentation showing 

completion of required initial or annual training. 

Recommendations	 6. We recommended that representatives from Nursing 

Service attend EOC rounds consistently, as required. 

7. We recommended that fire drills be conducted in 

accordance with NFPA requirements. 

8. We recommended that locked inpatient MH unit 

employees and members of the Multidisciplinary Safety 

Inspection Team receive required training on environmental 

hazards that represent a threat to suicidal patients. 

QM	 The purpose of this review was to evaluate whether the 

facility’s QM program provided comprehensive oversight of 

the quality of patient care and whether senior managers 

actively supported the program’s activities. We interviewed 

the facility’s Director, the Chief of Staff, and selected QM 

staff. We evaluated plans, policies, PI data, and other 

relevant documents. 

The QM program was generally effective in providing 

oversight of the facility’s quality of care, and senior managers 

supported the program through participation in and 

evaluation of PI initiatives and through the allocation of 

resources to the program. However, we identified the 

following QM areas that needed improvement. 

Life Support Training. VHA policy5 requires that all clinically 

active staff have life support education and that a system is 

in place to monitor compliance with ACLS and Basic Life 

4 Deputy Under Secretary for Health for Operations and Management, “Mental Health Environment of Care
 

Checklist,” memorandum, August 27, 2007.

5 VHA Directive 2008-008, Cardiopulmonary Resuscitation (CPR) and Advance Life Support (ACLS) Training for
 

Staff, February 6, 2008.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Support training or certification. The centralized monitoring 

system did not adequately track certification requirements for 

all staff designated to have this training. 

Medical Record Review. VHA policy6 requires medical 

record review to include the use of the copy and paste 

functions in the electronic medical record. We reviewed 

January to August 2010 Medical Record Committee minutes 

and found no documentation of monitoring results on the use 

of the copy and paste functions. 

Recommendations	 9. We recommended that the facility develop a process to 

accurately track compliance with life support training. 

10. We recommended that the Medical Record Committee 

monitor the use of the copy and paste functions. 

Medication	 The purpose of this review was to evaluate whether VHA 

Management facilities had developed effective and safe medication 

management practices. We reviewed selected medication 

management processes for outpatients and CLC residents. 

The facility complied with local criteria governing the 

maintenance of chronic renal disease patients who receive 

ESAs.7 We found that clinical staff had appropriately 

identified and addressed elevated hemoglobin levels in the 

10 patients whose medical records we reviewed. A fee basis 

provider regulated one patient’s ESA, and the primary care 

provider’s progress note reflected the laboratory results and 

the actions taken. Also, a qualified pharmacist is available 

24 hours a day, 7 days a week. However, we identified the 

following area that needed improvement. 

CLC Influenza Vaccinations. VHA8 requires that several 

items be documented for each influenza vaccine given, 

including the route, site, and date of administration. We 

reviewed the medical records of six CLC residents for 

vaccine documentation. Medical record documentation for 

only one of the six residents contained all the required 

elements. 

Recommendation	 11. We recommended that clinicians consistently document 

all required influenza vaccine elements. 

6 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 7 Drugs that stimulate the bone marrow to make red blood cells and are used to treat anemia. 

8 VHA Directive 2009-058, Seasonal Influenza Vaccine Policy for 2009–2010, November 12, 2009. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Review Activities Without Recommendations 

COC	 The purpose of this review was to evaluate whether 

inter-facility transfers and discharges were coordinated 

appropriately over the continuum of care and met VHA and 

JC requirements. Coordinated transfers and discharges are 

essential to an integrated, ongoing care process and optimal 

patient outcomes. 

VHA9 requires that facilities have a policy that ensures the 

safe, appropriate, and timely transfer of patients and that 

transfers are monitored and evaluated as part of the QM 

program. We determined that the facility had an appropriate 

transfer policy and that acceptable monitoring was in place. 

VHA requires specific information (such as the reason for 

transfer and services required) to be recorded in the transfer 

documentation. We reviewed documentation for 10 patients 

who transferred from the facility’s acute inpatient units or the 

emergency department to another facility. Clinicians 

generally documented the required elements. However, 

none of the 10 records contained the required AD elements 

in the transfer documentation. The facility reported that in 

June 2010, it modified the inter-facility transfer template to 

address the AD elements. While we were onsite, we 

reviewed the transfer documentation for 10 additional 

patients who had been transferred since June 2010. We 

determined that AD elements were included in the transfer 

documentation for all 10 patients. Therefore, we made no 

recommendation for this finding. 

VHA policy10 and JC standards require that providers include 

information regarding medications, diet, activity level, and 

follow-up appointments in written patient discharge 

instructions. We reviewed the medical records of 

10 discharged patients and determined that clinicians had 

documented all the required elements. In addition, we found 

that follow-up appointments occurred within the timeframes 

specified and that patients received a copy of the discharge 

instructions. We made no recommendations. 

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

facilities had consistent processes for physician C&P. For a 

sample of providers, we reviewed selected VHA required 

9 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 10 VHA Handbook 1907.01. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

elements in C&P files and physician profiles.11 We also 

reviewed meeting minutes during which discussions about 

the physicians took place. 

We reviewed 10 C&P files and profiles and found that 

licenses were current and that primary source verification 

had been obtained. FPPE was appropriately implemented 

for newly hired providers. Service-specific criteria for OPPE 

had been developed and approved. We found sufficient 

performance data to meet current requirements. Clinical 

Executive Board and Professional Standards Board meeting 

minutes consistently documented thorough discussions of 

the providers’ privileges and performance data prior to 

recommending renewal of or initial requested privileges. We 

made no recommendations. 

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 an environment that is safe. The 

facility’s SPD area is required to meet VHA, Association for 

the Advancement of Medical Instrumentation, OSHA, and JC 

standards. 

We inspected SPD, hemodialysis, gastrointestinal clinic, and 

operating room areas. We noted that traffic in the SPD 

areas was restricted to authorized personnel and that 

appropriate PPE was donned prior to entering the SPD 

reprocessing areas, as required. Appropriate infection 

prevention controls were in place, and the facility had a 

system in place to track RME should a sterilization failure 

occur. 

We reviewed the competency folders and training records of 

eight employees who demonstrated cleaning procedures and 

found that annual competencies and training were current 

and consistently documented. 

We reviewed the SOPs for reprocessing for seven pieces of 

RME. We found that six of the seven SOPs were well 

developed and consistent with the manufacturers’ 

instructions. While we were onsite, minor changes were 

made to one SOP to reflect actual practice and be consistent 

11 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Suicide Prevention 

Safety Plans 

with manufacturers’ guidelines. Therefore, we made no 

recommendation for this finding. 

VA12 requires that airflow be carefully controlled to minimize 

the movement of microorganisms from dirty areas to clean 

areas. We found that the air pressure in two areas where 

scopes are reprocessed—after being decontaminated in 

another area—were not under positive pressure. Changes 

were made while we were onsite to correct the air pressure 

in these areas. Therefore, we made no recommendations. 

The purpose of this review was to determine whether 

clinicians had developed safety plans that provided 

strategies to mitigate or avert suicidal crises for patients 

assessed to be at high risk for suicide. Safety plans should 

have patient and/or family input, be behavior oriented, and 

identify warning signs preceding crisis and internal coping 

strategies. They should also identify when patients should 

seek non-professional support, such as from family and 

friends, and when patients need to seek professional help. 

Safety plans must also include information about how 

patients can access professional help 24 hours a day, 7 days 

a week.13 

A previous OIG review of suicide prevention programs in 

VHA facilities14 found a 74 percent compliance rate with 

safety plan development. The safety plan issues identified in 

that review were that plans were not comprehensive (did not 

contain the above elements), were not developed timely, or 

were not developed at all. At the request of VHA, the OIG 

agreed to follow up on the prior findings. 

We reviewed the medical records of 10 patients assessed to 

be at high risk for suicide and found that 9 (90 percent) of the 

10 patients had safety plans in place. We found that 

clinicians had developed the safety plans within a reasonable 

time after identification of the patients’ high-risk status. We 

made no recommendations. 

12 VA Handbook 7176; Supply, Processing and Distribution (SPD) Operational Requirements; August 16, 2002. 13 Deputy Under Secretary for Health for Operations and Management, “Patients at High-Risk for Suicide,” 

memorandum, April 24, 2008.

14 Healthcare Inspection – Evaluation of Suicide Prevention Program Implementation in Veterans Health 

Administration Facilities January–June, 2009; Report No. 09-00326-223; September 22, 2009. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, 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 19–24, for the full text of the Directors’ comments.) We consider 

recommendations 1, 2, 3, 4 and 11 closed. We will follow up on the planned actions for 

the open recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Appendix A 

Facility Profile15 

Type of Organization Medical center 

Complexity Level 1c 

VISN 8 

CBOCs Boca Raton, FL 

Delray Beach, FL 

Fort Pierce, FL 

Stuart, FL 

Okeechobee, FL 

Vero Beach, FL 

Veteran Population in Catchment Area 177,318 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP16 140 

 CLC/Nursing Home Care Unit 120 

 Other N/A 

Medical School Affiliation(s) University of Miami 

Columbia Hospital/Palm Beach Centre for 

Graduate Medical Education 

Nova Southeastern University, School of 

Medicine 

Nova Southeastern University, School of 

Dentistry 

 Number of Residents 38 medicine and 2.5 dental 

Current FY (through 

September 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $321.4 $309.5 

 Medical Care Expenditures $321 $308.7 

Total Medical Care FTE 2,121.93 2,105.51 

Workload: 

 Number of Station Level Unique 

Patients 

57,699 61,569 

 Inpatient Days of Care: 

o Acute Care 31,490 37,400 

o CLC/Nursing Home Care Unit 27,653 33,534 

Hospital Discharges 5,347 7,176 

Total Average Daily Census (including all bed 

types) 

194.5 194.3 

Cumulative Occupancy Rate 81.74% 75.62% 

Outpatient Visits 639,386 609,301 

15 All data provided by facility management.
 16 Psychosocial Residential Rehabilitation Treatment Program.
 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Appendix B 

Follow-Up on Previous Recommendations 

OIG Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Correct the electrical closet and the 

television and video camera recorder 

electrical cord conditions on the locked MH 

unit. 

Electronic equipment cord lengths 

were corrected (less than 12 inches). 

Staff was educated on equipment 

safety related to electrical cords and 

electrical closets. Units are being 

monitored daily by nurse managers 

and on a quarterly basis. 

Y N 

2. Require the Multidisciplinary Safety 

Inspection Team to complete a risk 

assessment and action plan to address the 

environmental hazards in the room 

designated for MH patients in the emergency 

department. 

The risk assessment was completed, 

and all environmental physical 

improvements were completed in 

August 2008. Emergency department 

patients identified as high risk are 

placed on a 1:1 status to ensure 

patient and staff safety. 

Y N 

3. Require CLC nursing staff to comply with 

IC guidelines for patients on isolation 

precautions. 

An intensive educational program was 

developed by the IC and MRSA 

Coordinator and includes hand 

hygiene, isolation precautions, and the 

MRSA initiative. IC monitoring is being 

conducted through routine data pulls, 

visual inspections, and internal tracers. 

Y N 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

OIG Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

4. Require contaminated equipment to be 

clearly identified and stored separately from 

clean supplies. 

Contaminated equipment was removed 

from the clean supply room during the 

CAP review. Re-education was 

provided to nursing and to 

Environmental Management Service 

staff on the importance of isolating 

clean from dirty supplies and 

equipment. Monitors are in place and 

are being conducted during 

environmental rounds and through 

internal tracers. 

Y N 

5. Maintain the security of confidential patient 

information. 

Staff is initially educated on ensuring 

patient information confidentiality and 

computer security during mandatory 

new employee education. Importance 

is reinforced through ongoing training. 

Y N 

6. Maintain the security of housekeeping 

closets, housekeeping carts, and cleaning 

solutions. 

Environmental Management Service 

staff completed additional training on 

maintaining security of housekeeping 

closets, carts, and all solutions. 

Compliance is monitored by 

supervisors and during environmental 

rounds and internal tracers. 

Y N 

7. Provide privacy for all patients on the 

chemotherapy unit. 

The outpatient chemotherapy unit was 

evaluated, and additional curtains were 

added so that each lounger has a 

privacy screen. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

OIG Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

8. Require staff to conduct and document 

weekly preventative maintenance inspections 

of the WanderGuard® system. 

Preventative maintenance checks on 

the WanderGuard® system are 

completed weekly, and oversight was 

assigned to an Environmental 

Management Services supervisor to 

ensure documentation compliance. 

Y N 

QM 

9. Require timely completion of peer 

reviews and the presentation of trending and 

analysis data to the Clinical Executive 

Board, as required by VHA policy. 

Peer review reports have been 

completed and reported to the VISN 

and are now being reported quarterly 

to the Clinical Executive Board. 

Y N 

10. Require that mechanisms are in place to 

adequately evaluate adverse events that 

could potentially require disclosure. 

The tracking system for Patient 

Incident Worksheets has been 

reviewed and improved to identify the 

timeline involved and all actions taken. 

A clinical disclosure template has been 

added to the institutional disclosure 

template currently in use. Patient 

Incident Worksheets are reviewed by 

the Chief of Staff to evaluate the need 

for disclosure. 

Y N 

Pharmacy Operations 

11. Require that all controlled substance 

inspectors complete appropriate training and 

competency reviews and that the results are 

documented. 

An annual process has been 

implemented for all controlled 

substance inspectors to complete the 

annual training in the month of 

September to ensure compliance for 

the upcoming year. 

Y N 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

OIG Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

12. Require that clinical pharmacists 

complete monthly polypharmacy reviews on 

all CLC patients, as required by the JC. 

The pharmacy has instituted a weekly 

polypharmacy chart review action that 

will identify all patients due for a 

polypharmacy review. Pharmacy 

monitors the process and reports to the 

Medication Use Committee monthly. 

Y N 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Appendix C 

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

facility performance. Patients are surveyed monthly. VHA is currently in the process of 

transitioning to the Consumer Assessment of Healthcare Providers and Systems 

survey. As a result, data for FY 2009 have been summarized for the entire year. 

Table 1 below shows facility, VISN, and VHA calibrated overall inpatient and outpatient 

satisfaction scores for FY 2009 and overall inpatient and outpatient satisfaction scores 

and targets for the 1st and 2nd quarters of FY 2010. 

Table 1 

FY 2009 FY 2010 

(inpatient target = 64; outpatient target = 56) 

Inpatient 

Score 

Outpatient 

Score 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Facility 70.29 50.75 68.9 65.4 60.7 59.2 

VISN 67.18 57.38 65.8 68.3 58.1 56.8 

VHA 65.01 52.87 63.3 63.9 54.7 55.2 

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 17 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

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

conditions17 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 CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 13.55 8.34 13.37 20.02 16.72 15.24 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

17 Congestive heart failure (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 sedition of 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 18 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 20, 2010 

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

Subject: CAP Review of the West Palm Beach VA Medical Center, 

West Palm Beach, FL 

To: Director, 

(54SP) 

St. Petersburg 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 West 

Palm Beach VA Medical Center, West Palm Beach, Florida. 

2. Corrective action plans have been established with planned completion 

dates, as detailed in the attached report. 

(original signed by:) 

Nevin M. Weaver, FACHE 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 20, 2010 

From: Director, West Palm Beach VA Medical Center (548/00) 

Subject: CAP Review of the West Palm Beach VA Medical Center, 

West Palm Beach, FL 

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. 

(original signed by:) 

Charleen R. Szabo, FACHE 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, 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 security of the “mobile” MRI unit be 

strengthened. 

Concur 

Completed: September 27, 2010 

Before the OIG exit briefing, a panic button was installed underneath the desk in the 

MRI “mobile” unit. This panic button has been tested and verified operational by VA 

Police. In case of emergency, the MRI Technologist pulls the handle and VA police 

respond to the area immediately. Staff has been educated in the use of the panic 

button. The MRI “mobile” unit door now is locked per policy at all times and 

environmental rounds were conducted on December 13, 2010, by QM and the MRI 

Safety Officer, validating the door was locked. An “MRI Safe” (green color-coded) 

sticker was placed on the MRI mobile unit stretcher and all other MRI compatible 

equipment on October 4, 2010. Environmental rounds conducted on 

December 13, 2010, by QM and the MRI Safety Officer validated the stretcher had the 

sticker in place and was in the designated safe area. 

Recommendation 2. We recommended that equipment used in MRI areas be properly 

labeled as safe or unsafe and that the MRI compatible ventilator be properly cleaned 

and maintained after use to ensure that unsafe supplies are not left with the equipment. 

Concur 

Completed: December 14, 2010 

All equipment in MRI Mobile and MRI Suite 1B344 has been labeled with color coded 

“MRI Safe” and “MRI Unsafe” stickers (Red=Unsafe and Green=Safe) by the MRI 

Safety Officer. An SOP was developed on December 12, 2010, by Anesthesia, with a 

Memo of Understanding between Imaging and Anesthesia to ensure the anesthesia cart 

is kept in the MRI suite, and is cleaned and maintained after use. A monthly report is 

now required as a standing agenda item for MRI meetings to track and trend anesthesia 

cart maintenance compliance in the minutes. Issues identified during cart use will have 

corrective actions implemented and followed by Anesthesia to ensure future 

compliance. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Recommendation 3. We recommended that a physical barrier be placed in the 

Radiology Service MRI suite to prevent unauthorized or accidental entry to Zones III 

and IV. 

Concur 

Completed: December 8, 2010 

Before the OIG exit briefing, a keypad lock was installed on the double door entrance to 

the MRI Suite 1B-344 to restrict access. Engineering completed the MRI 

reconfiguration on December 8, 2010, when a wall was installed to separate the CT 

scan screening area from MRI. A curtain was placed in Zone II for patient privacy 

during the screening process. The camera was repositioned in the MRI Suite to ensure 

security and safety of patients and staff. 

Recommendation 4. We recommended that MRI staff comply with local policy and the 

manufacturer’s guidelines regarding use of the ferromagnetic detector. 

Concur 

Completed: December 15, 2010 

The MRI Safety Officer revised MRI Safety Policy based on Manufacturer’s Guidelines 

of the Ferralert®, and all staff are following these guidelines. MRI technologists have 

been trained by the MRI Safety Officer on the proper use of the Ferralert®. The 

Ferralert® was re-positioned to ensure it is used appropriately. If the yellow light/alarm 

goes off, the MRI Technician is to investigate and identify ferromagnetic objects. The 

patient is pre-screened in a private room before entering the Ferralert®. 

Recommendation 5. We recommended that emergency code drills be conducted in 

MRI areas. 

Concur 

Completed: October 25, 2010 

Emergency code drills (Code Blue & Code Green) were conducted on 

October 25, 2010, and Code Green drills were conducted on December 15, 2010, by 

the MRI Safety Officer, in collaboration with Education Service. Emergency code drills 

will be conducted quarterly. Code Blue drills will be reported and documented in the 

minutes of the CRC Committee, and Code Green drills will be reported and documented 

in the minutes of the Disturbed Behavior Committee to ensure compliance. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Recommendation 6. We recommended that representatives from Nursing Service 

attend EOC rounds consistently, as required. 

Concur 

Completed: September 9, 2010 

Nursing Service assigned a registered nurse representative, and two additional 

alternate staff members to ensure coverage, to participate in the EOC rounds. EOC 

attendance sheets will support consistent participation. 

Recommendation 7. We recommended that fire drills be conducted in accordance 

with NFPA requirements. 

Concur 

Completed: October 28, 2010 

Fire drills are being conducted once per shift per quarter in each building defined as 

healthcare occupancy. The CLC had drills completed on the October 28, 2010, day 

shift, the November 15 evening shift, and one is scheduled for the December 23 night 

shift to complete the FY11 Qtr 1 schedule. 

Recommendation 8. We recommended that locked inpatient MH unit employees and 

members of the Multidisciplinary Safety Inspection Team receive required training on 

environmental hazards that represent a threat to suicidal patients. 

Concur 

Target date for completion: December 31, 2010 

Mental Health and Nursing identified clinical staff that permanently work in Mental 

Health areas as well as those that respond to Code Blue, Rapid Response, and Code 

Green for training. Currently all identified key staff, except two individuals, have 

completed the training. Additionally, the decision was made to require all clinical staff to 

complete this training and it has been added to the Learning Management System 

(LMS) to ensure accurate tracking and annual compliance, to be completed by 

December 31, 2010, and then annually. As new staff come on board Nursing and MH 

will notify Education so that those individuals have the required training entered into 

LMS. Both MH and Nursing will be given a monthly report to verify compliance. 

Recommendation 9. We recommended that the facility develop a process to 

accurately track compliance with life support training. 

Concur 

Completed: October 25, 2010 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

At the time of the OIG survey, individual services were required to track ACLS 

compliance. To simplify the process and improve compliance tracking and reporting, 

the decision was made that clinical staff that required ACLS training would be identified 

and Education has entered ACLS training as a mandatory requirement in LMS, based 

on their bi-annual renewal date. A deficiency report will be generated by Education and 

reported to the services monthly and CEB quarterly. As new staff are hired, 

Credentialing and Nursing will identify ACLS needs and report to Education so LMS can 

be maintained. 

Recommendation 10. We recommended that the Medical Record Committee monitor 

the use of the copy and paste functions. 

Concur 

Completed: November 4, 2010 

“Copy and Paste” was one of the elements in the existing pertinence review tool 

submitted by all clinical services. Reporting on “Cutting and Paste” has been added as 

a standing Medical Records Committee (MRC) agenda item to capture discussion in the 

minutes. Based on OIG recommendations during the survey, FY10 “Copy and Paste” 

data previously reported was analyzed and reported to MRC November 4, 2010. 

Recommendation 11. We recommended that clinicians consistently document all 

required influenza vaccine elements. 

Concur 

Completed: October 29, 2010 

Employee education was provided to all nurses and nurses signed a document to verify 

that they understood expectations for documentation requirements for Influenza 

Vaccines in the Bar Coded Medication Administration (BCMA) system. CLC audits 

were conducted on 72 patients by Nurse Managers in collaboration with the BCMA 

Coordinator. The audit reflected 100 percent compliance for the month of October, 

(seasonal month for Influenza vaccines) validating that influenza vaccine education 

provided by the CLC Clinical Nurse Specialist and the BCMA Coordinator was effective. 

Future monitoring will be conducted quarterly and non-compliance will be addressed 

through re-education tracked by the CLC Clinical Nurse Specialist and the CLC Nurse 

Managers. Quarterly reports will be submitted to the Nurse Practice Council to track 

compliance. 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, FL 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Christa Sisterhen, Director 

St. Petersburg Office of Healthcare Inspections 

Contributors Darlene Conde-Nadeau, Team Leader 

Alice Morales-Rullan 

Annette Robinson 

Karen Sutton 

Carol Torczon 

Idell Graham 

David Spilker, Office of Investigations 

Report Produced under the direction of Christa Sisterhen 

Preparation Director, St. Petersburg Office of Healthcare Inspections 

VA OIG Office of Healthcare Inspections 25 
CAP Review of the West Palm Beach VA Medical Center, West Palm Beach, 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, West Palm Beach VA Medical Center (548/00) 

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: Alcee L. Hastings, Bill Posey, Tom Rooney, Allen West 

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

VA OIG Office of Healthcare Inspections 26