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The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Miami VA Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health (MH) Residential Rehabilitation Treatment Program. OIG also provided crime awareness briefings to 79 employees. The facility has stable executive leadership and active engagement with employees and patients. Organizational leaders supported patient safety, quality care, and other positive outcomes by enacting processes and plans to maintain positive perceptions of the facility through active stakeholder engagement. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Senior leaders were knowledgeable about selected SAIL metrics and continue to take actions to improve care and performance. OIG noted findings in six of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) QSV • Review of credentialing and privileging data every 6 months • Physician utilization management advisor’s documentation of decisions (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and reporting (3) EOC • EOC rounds attendance and frequency • Locked MH unit panic alarm testing (4) High-Risk Processes: Moderate Sedation • Informed consent notification of provider changes and documentation (5) Long-Term Care: CNH Oversight • CNH Oversight Committee requirements • Annual reviews of CNHs • Cyclical clinical visits (6) MH Residential Rehabilitation Treatment Program • Daily room inspections for unsecured medications

The OIG conducted a healthcare inspection to assess concerns about possible abuse, neglect, or financial exploitation of veterans residing in medical foster homes (MFH) operated by Mr. and Mrs. X under the purview of the Chalmers P. Wylie VA Ambulatory Care Center (facility), Columbus, Ohio. The OIG did not substantiate veterans residing in MFH-1 were at imminent risk for abuse or neglect. The OIG could not substantiate that the two veterans who designated Mr. X as financial power of attorney (POA) were at imminent risk for financial exploitation. Veterans Health Administration (VHA) policy discourages MFH caregivers from managing the financial affairs of their residents, but the veterans appeared to have decision-making capacity and were satisfied with the designation. After determining the MFHs were in violation of VHA policy, the facility revoked VA’s approval for all of Mr. and Mrs. X’s MFHs. However, the facility’s MFH coordinator did not consistently facilitate communication, collaboration, and follow-up, which may have limited joint problem-solving opportunities that would have allowed the MFHs to remain in good standing. VA-approved MFHs must meet state licensure requirements as outlined in Ohio Administrative Code (OAC) Chapter 5122-33 Adult Care Facility (ACF) Regulations. The OAC applies to facilities with 3–16 unrelated adults, at least 3 of whom require personal care. VA-approved MFHs housing only veterans are not required to have an actual state license. Because MFH-1 now has three unrelated adults requiring personal care but does not have official VA MFH designation, it is subject to OAC regulations, which prohibits ACF staff from holding a resident’s POA. According to Ohio regulations, MFH-1 must also secure state licensure to operate legally as an MFH. Although VHA policy was silent on reporting cases of MFH revocation to outside entities, MFH staff had notified state authorities that veterans still resided in MFH-1.