Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02079-287 

Combined Assessment Program
 

Review of the
 

West Texas VA Health Care System
 

Big Spring, Texas
 

September 21, 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 Texas VA Health Care System, Big Spring, TX 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

EN enteral nutrition 

EOC environment of care 

facility West Texas VA Health Care System 

FY fiscal year 

MEC Medical Executive Committee 

MH RRTP Mental Health Residential Rehabilitation Treatment 

Program 

OIG Office of Inspector General 

PSB Professional Standards Board 

QM quality management 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

EN Safety .......................................................................................................... 3
 

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

Physician C&P................................................................................................... 5
 

RN Competencies ............................................................................................. 6
 

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

Coordination of Care ......................................................................................... 6
 

Management of Workplace Violence................................................................. 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................ 11
 

D. VISN Director Comments .................................................................................. 13
 

E. Facility Director Comments ............................................................................... 14
 

F. OIG Contact and Staff Acknowledgments ......................................................... 19
 

G. Report Distribution ............................................................................................ 20
 

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

Review of the West Texas VA Health Care System, 

Big Spring, TX 

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 

July 11, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

 Coordination of Care 

 Management of Workplace Violence 

Recommendations: We made 

recommendations in the following five 

activities: 

Quality Management: Ensure all 

required members attend assigned 

committee meetings. Ensure that all 

required components of pre-sedation 

assessments are documented prior to 

sedation and that compliance is 

monitored. Ensure that all required 

components are included in 

resuscitation event reviews and medical 

records reviews and that compliance is 

monitored. 

Enteral Nutrition Safety: Ensure enteral 

nutrition documentation includes all 

required elements. 

Environment of Care: Ensure that 

annual bloodborne pathogens training is 

completed and that compliance is 

monitored. Ensure that all laser 

operators comply with the facility laser 

safety policy. Require that Mental 

Health Residential Rehabilitation 

Treatment Program inspections are 

conducted at required intervals, include 

all elements, and are documented. 

Physician Credentialing and Privileging: 

Ensure that the Professional Standards 

Board submits actions and 

recommendations for privileging and 

reprivileging to the Medical Executive 

Committee and that Medical Executive 

Committee meeting minutes include 

documentation of reviews and 

decisions. 

Registered Nurse Competencies: 

Ensure competency validation 

documentation is complete and 

specifies the methods used to assess 

and validate competency. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

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: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through July 8, 2011, and was done in accordance 

with OIG standard operating procedures for CAP reviews. 

We also followed up on selected recommendations from 

our prior CAP review of the facility (Combined Assessment 

Program Review of the West Texas VA Health Care 

System, Big Spring, Texas, Report No. 08-03043-70, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

February 19, 2009). The facility had corrected all previous 

findings. (See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 63 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 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement. 

QM Oversight. VHA requires each facility to provide 

oversight to ensure that QM components are implemented, 

integrated, and documented.1 The facility used the Quality 

Executive Board to provide oversight of clinical activities. 

We found that required members did not regularly attend 

assigned committee meetings. We reviewed minutes from 

October 2009–March 2011 and found that two required 

members of senior leadership did not attend any 

meetings during this period. We also reviewed Infection 

Prevention and Wellness Committee minutes from 

October 2010–April 2011 and found that 3 of the 16 required 

members did not attend any meetings during this period. 

Moderate Sedation. VHA requires that a licensed 

independent practitioner complete a pre-sedation 

assessment that includes all required components prior to 

patient sedation.2 We reviewed the medical records of 

10 patients who received moderate sedation and found 

1 VHA Directive 2009-043, Quality Management System, September 11, 2009. 2 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

5 pre-sedation assessments where the licensed independent 

practitioner did not document all the required components, 

such as airway or risk assessment. 

Resuscitation and Its Outcomes. VHA requires that facilities 

have a designated Cardiopulmonary Resuscitation 

Committee to evaluate each resuscitation event using 

specific review components.3 While reviews of resuscitation 

events were completed, the reviews did not include all the 

required components, such as errors or deficiencies in 

technique and delays in initiating cardiopulmonary 

resuscitation. 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include specific areas of review.4 

While medical record quality reviews had been completed, 

we found that they did not include all of the required 

components. For example, we found that the facility did not 

review a representative sample of records from each 

program/service area and did not monitor unauthenticated 

documentation. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that all required members attend assigned committee 

meetings. 

2. We recommended that processes be strengthened to 

ensure that all required components of the pre-sedation 

assessment are documented by the licensed independent 

practitioner prior to sedation and that compliance is 

monitored. 

3. We recommended that resuscitation event review 

processes be strengthened to ensure that all required 

components are included and that compliance is monitored. 

4. We recommended that medical record review processes 

be strengthened to ensure that all required components are 

included and that compliance is monitored. 

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

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

3 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 4 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

We reviewed policies and documents related to EN and 

patients’ medical records. We inspected areas where EN 

products were stored while conducting the EOC review, and 

we interviewed key employees. We identified the following 

area that needed improvement. 

EN Documentation. VHA requires that staff document 

specific EN information in patients’ medical records.5 We 

reviewed the medical records of 11 EN patients and found 

that 2 records did not contain all required information. For 

example, neither record included documentation of x-ray 

confirmation of Dobhoff tube6 placement. 

Recommendation	 5. We recommended that processes be strengthened to 

ensure that EN documentation includes all required 

elements. 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements and whether the 

facility’s domiciliary was in compliance with selected MH 

RRTP requirements. 

We inspected the medical-surgical unit; the community living 

center; the urgent care, primary care, ophthalmology, and 

dental clinics; the day procedure unit; and the domiciliary. 

The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement. 

Infection Control. The Occupational Safety and Health 

Administration requires that employees with occupational 

exposure risk receive annual training on the Occupational 

Safety and Health Administration Bloodborne Pathogens 

Rule. We reviewed 25 employee training records and found 

that 10 employees did not have this training documented. 

Laser Safety. Local policy requires that all laser procedures 

are performed in the ophthalmology clinic and that laser 

users are credentialed physicians or nurses. We found that 

physical therapists had been operating lasers in the Physical 

Therapy Department. 

MH RRTP Inspections. VHA requires facilities to conduct 

and document monthly MH RRTP self-inspections that 

5 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007.
 6 A Dobhoff tube is a feeding tube that is inserted in the nose and goes through the throat into the stomach.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Recommendations 

Physician C&P 

Recommendation 

include safety, security, and privacy.7 VHA also requires that 

MH RRTP staff conduct and document public area 

inspections for contraband regularly and randomly, resident 

room inspections for unsecured medications daily and 

randomly, and public area inspections for safety and security 

every 2 hours. We found that monthly self-inspections did 

not include security and privacy. Additionally, we did not find 

documentation of inspections of public areas for contraband, 

random inspections of resident rooms for unsecured 

medications, or inspections of public areas every 2 hours. 

6. We recommended that annual bloodborne pathogens 

training be completed and that compliance be monitored. 

7. We recommended that processes be strengthened to 

ensure that all laser operators comply with the facility laser 

safety policy. 

8. We recommended that processes be strengthened to 

ensure that all MH RRTP inspections are conducted at 

required intervals, include all elements, and are documented. 

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 15 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following area that needed improvement. 

MEC Oversight of PSB. VHA requires that PSB actions and 

recommendations be submitted to the MEC for review and 

approval.8 MEC meeting minutes did not include 

documentation of the review or approval of PSB privileging 

or reprivileging recommendations prior to granting privileges 

for the 15 physicians whose folders we reviewed. 

9. We recommended that the PSB submit actions and 

recommendations for privileging and reprivileging to the MEC 

and that MEC meeting minutes include documentation of 

reviews and decisions. 

7 VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program (MH RRTP),
 

May 26, 2009.

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

RN Competencies	 The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility processes, interviewed nurse managers, 

and reviewed initial and ongoing competency assessment 

and validation documents for 12 RNs. We identified the 

following areas that needed improvement. 

Competency Validation Documentation. The Joint 

Commission requires that nursing personnel are competent 

to perform their responsibilities. Eight RN competency 

folders had documentation deficiencies. The RN assessing 

competency did not sign and date each competency 

individually as required by the form. 

Competency Validation Methods. The Joint Commission 

requires facilities to specify the assessment methods used 

(such as test taking, demonstration, or simulation) to 

determine an individual’s competency in required skills. 

Additionally, local policy requires validation of each skill listed 

in the RN’s competency folder. Seven of the RN 

competency folders reviewed did not have reviewer 

documentation of the assessment methods for the skills 

listed. 

Recommendation	 10. We recommended that processes be strengthened to 

ensure that competency validation documentation is 

complete and specifies the methods used to assess and 

validate competency. 

Review Activities Without Recommendations
 

Coordination of 

Care 

Management of 

Workplace 

Violence 

The purpose of this review was to evaluate whether the 

facility managed advance care planning and advance 

directives in accordance with applicable requirements. 

We reviewed patients’ medical records and the facility’s 

advance care planning policy and determined that the facility 

generally met VHA requirements. We made no 

recommendations. 

The purpose of this review was to determine whether VHA 

facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

We reviewed the facility’s policy and training plan. 

Additionally, we selected three assaults that occurred at the 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

facility within the past 2 years, discussed them with 

managers, and reviewed applicable documents. The facility 

had a comprehensive workplace violence policy and 

managed the assaults in accordance with policy. The 

training plan addressed the required prevention and 

management of disruptive behavior training. We made no 

recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 13–18, for the full text of the Directors’ comments.) We consider 

Recommendation 10 closed. We will follow up on the planned actions for the open 

recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Appendix A 

Facility Profile9 

Type of Organization Veterans Rural Access Hospital 

Complexity Level 3 

VISN 18 

Community Based Outpatient Clinics Abilene, TX 

Odessa, TX 

San Angelo, TX 

Hobbs, NM 

Ft. Stockton, TX (outreach clinic) 

Stamford, TX (outreach clinic) 

Veteran Population in Catchment Area 70,000 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

20 

 Community Living Center/Nursing 

Home Care Unit 

40 

 Other 12 (domiciliary) 

Medical School Affiliation(s) Texas Tech University 

 Number of Residents 4 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

March 2011) 

$92.6 

Prior FY (2010) 

$94.8 

 Medical Care Expenditures $44.5 $93.1 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

548 

14,091 

534 

549 

17,321 

1,968 

o Community Living 

Center/Nursing Home Care Unit 

6,345 12,282 

Hospital Discharges 130 433 

Total Average Daily Census (including all bed 

types) 

49.5 50.2 

Cumulative Occupancy Rate (in percent) 61.89 68.80 

Outpatient Visits 70,954 148,248 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure that root cause analyses are 

completed within 45 days. 

The Patient Safety Manager monitors 

progress of individual and aggregate 

root cause analyses to completion. All 

root cause analyses chartered since 

March 2008 have been completed 

within 45 days or less. 

Y N 

2. Ensure that medical records are reviewed 

on an ongoing basis at the point of care by 

providers who document in the record, in 

accordance with VHA policy. 

The Ongoing Professional Practice 

Evaluation plan was written and 

implemented after the CAP and has 

been maintained. 

Y N 

3. Ensure that the copy and paste function 

in the electronic medical record is monitored 

to identify violations, in accordance with 

local policy. 

Provider medical record entries are 

reviewed on a monthly basis at the 

point of care for clinical pertinence, 

quality, and appropriateness of care. 

Review results are reported to the 

Medical Records Committee monthly 

and to the Quality Executive Board 

quarterly. 

Y N 

Medication Management 

4. Ensure that clinicians document pain 

medication effectiveness in a timely manner. 

Review of documentation of pain 

effectiveness monitors was at or above 

a collective score of 90 percent for the 

previous 12 months. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

5. Ensure that identified EOC deficiencies are 

corrected. 

Follow-up EOC rounds take place 

11 days after initial report to check for 

completion. Service chiefs receive 

weekly progress reports on the 

correction of EOC deficiencies. The 

85 percent completion target has been 

met since the 4th quarter of FY 2008. 

Y N 

Pharmacy Operations and Controlled 

Substance Inspections 

6. Ensure that monthly controlled substances 

inspections are completed the day initiated. 

Controlled substance inspections for 

the past 2 years were all completed on 

the day initiated. 

Y N 

Emergency/Urgent Care Operations 

7. Ensure that RNs who work in the urgent 

care clinic achieve the required clinical 

competencies annually. 

All annual RN competencies for the 

urgent care clinic are in compliance. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

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 3 and 4 of FY 2010 and quarters 1 and 2 of FY 2011. 

Table 1 

FY 2010 FY 2011 

Inpatient Score 

Quarters 3–4 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Inpatient Score 

Quarters 1–2 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Facility 65.5 51.0 53.0 69.8 44.2 45.5 

VISN 64.1 53.1 52.8 64.6 52.5 52.0 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

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

scores for 2009, 2010, and 2011. 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 

2009 2010 2011 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

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

conditions10 received hospital care. The mortality (or death) rates focus on whether 

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

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

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

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

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

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

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

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

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility * 9.29 16.86 * 21.08 14.73 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

* Not enough cases 

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

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

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

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

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

and fatigue. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 August 26, 2011 

From:	 Network Director, VISN 18 (10N18) 

Subject:	 CAP Review of the West Texas VA Health Care System, 

Big Spring, TX (519/00) 

To:	 Director, Dallas Office of Healthcare Inspections (54DA) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I concur with the recommendations for improvement contained in the 

Combined Assessment Program review at the West Texas VA Health 

Care System. If you have any questions or concerns, please contact Sally 

Compton, Executive Assistant to the Network Director, VISN 18, at 

602-222-2699. 

(original signed by:) 

Susan P. Bowers 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 August 22, 2011 

From:	 WTVAHCS Facility Director 

Subject:	 CAP Review of the West Texas VA Health Care System, 

Big Spring, TX (519/00) 

To:	 Director, VA Southwest Health Care Network (10N18) 

I concur with the attached facility update on the recommendations for 

improvement contained in the Combined Assessment Program review at 

the West Texas VA Health Care System. If you have any questions or 

concerns, please contact Rosa Mancha, Quality Manager, WTVAHCS at 

432 264-4832. 

(original signed by:) 

Mr. Daniel L. Marsh 

Director, West Texas VA Healthcare System (519/00) 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Comments to Office of Inspector General’s Report
 

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

in the Office of Inspector General report: 

OIG Recommendations 

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

all required members attend assigned committee meetings. 

Concur 

Target date for completion: September 30, 2011 

Quality Management will add a component to monitor committee meeting attendance to 

the committee minute review checklist and will provide a summary of facility committee 

attendance to the Quality Executive Board. 

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

all required components of the pre-sedation assessment are documented by the 

licensed independent practitioner prior to sedation and that compliance is monitored. 

Concur 

Target date for completion: September 30, 2011 

The pre-sedation assessment template was updated to include the American Society of 

Anesthesiology preoperative assessment and the Mallampati airway classification. 

Education has been provided to the contract provider by the Chief of Medicine. The 

licensed provider and a nursing representative will review all records of patients that 

require sedation to assure all documentation is provided. Their findings will be 

presented monthly to the Operative and Invasive Procedure Review Committee. 

Recommendation 3. We recommended that resuscitation event review processes be 

strengthened to ensure that all required components are included and that compliance 

is monitored. 

Concur 

Target date for completion: September 30, 2011 

The code evaluation sheet was updated by the Monitored Care Unit/Cardio Pulmonary 

Resuscitation (MCU/CPR) Committee to include required components such as errors or 

deficiencies in technique, and delays in initiating CPR. Education will be provided to 

nursing staff by the Nurse Educator. MCU/CPR Committee members will be educated 

by the Committee Chair during the next quarterly MCU/CPR Committee meeting 

scheduled in September 2011. Physicians will be educated by the Chair, MCU/CPR 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Committee during the monthly Medical Staff meeting. The Chair of the MCU/CPR 

Committee, Urgent Care Nurse Manager and the Risk Manager will review 100 percent 

of Code Blues within 72 hours to assure all documentation is provided. MCU/CPR 

Committee meetings will be held at the call of the Risk Manager to address urgent 

findings and opportunities for improvements. Findings and trends will be documented in 

the MCU/CPR minutes. 

Recommendation 4. We recommended that medical record review processes be 

strengthened to ensure that all required components are included and that compliance 

is monitored. 

Concur 

Target date for completion: September 30, 2011 

The Chief of Health Information Management Section will run a monthly report to 

monitor 100 percent of unauthenticated-unsigned notes. Correction will be requested 

from providers, and non-compliance will be referred to Service Chiefs for follow up and 

appropriate action. Results will be presented to the Medical Record Review Committee. 

Reviews will include a random sample from each service area. In addition, required 

review elements are included in the Ongoing Professional Practice Evaluation reviews 

and reported at the quarterly Medical Record Review Committee for appropriate follow 

up. 

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

EN documentation includes all required elements. 

Concur 

Target date for completion: September 30, 2011 

An addendum will be added to the Medicine Service Policy requiring documentation of 

provider review of nasogastric feeding tube placement. Compliance will be monitored 

by Chief of Medicine or designee and reported monthly to the Medical Staff. 

Recommendation 6. We recommended that annual bloodborne pathogens training be 

completed and that compliance be monitored. 

Concur 

Target date for completion: September 16, 2011 

Bloodborne pathogen education was designated as mandatory for all employees in the 

VA’s Talent Management System. Percentage of completion will be reported weekly to 

Executive Leadership with a listing of the individual(s) who are overdue in their training. 

Results will be forwarded to service chiefs on a weekly basis. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Recommendation 7. We recommended that processes be strengthened to ensure that 

all laser operators comply with the facility laser safety policy. 

Concur 

Target date for completion: September 30, 2011 

The WTVAHCS laser safety policy will be updated to include Physical Therapists as 

laser operators to enable the use of laser therapy as a modality in Physical Therapy and 

ensure that all laser operators comply with the policy. 

Recommendation 8. We recommended that processes be strengthened to ensure that 

all MH RRTP inspections are conducted at required intervals, include all elements, and 

are documented. 

Concur 

Target date for completion: August 23, 2011 

Chief of Domiciliary Services made immediate changes to the existing tracking 

process/logs to ensure the appropriate inspections occur as required, within required 

intervals, and include all elements. Specifically: 

1.	 The Monthly Self-Inspection Log now includes sections on privacy, safety, and 

security. 

2.	 The DRRTP Bed/Wellness Check/Building Inspection/Daily Rounds process/log 

was changed to include: 

a.	 Daily scheduled checks of resident rooms and common/public areas for 

unsecured medication/contraband. 

b.	 Daily random unsecured medication/contraband checks of resident rooms 

and common/public areas. 

c.	 Regularly scheduled (every 2 hours of all public areas) safety/security checks. 

d.	 All checks/logs are kept in a DRRTP shared computer drive. DRRTP RN will 

monitor daily compliance and report weekly to the DRRTP Chief. Monitoring 

will occur until four successive weeks of full compliance are noted. Random 

checks will then continue through tracer activity. 

Recommendation 9. We recommended that the PSB submit actions and 

recommendations for privileging and reprivileging to the MEC and that MEC meeting 

minutes include documentation of reviews and decisions. 

Concur 

Target date for completion: August 23, 2011 

Professional Standards Committee submits recommendations for privileging and 

re-privileging of providers to the MEC prior to Director approval. MEC minutes now 

reflect Professional Standards Committee submitted actions and recommendations for 

MEC review and decision as a standing agenda item. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Recommendation 10. We recommended that processes be strengthened to ensure 

that competency validation documentation is complete and specifies the methods used 

to assess and validate competency. 

Concur 

Target date for completion: August 22, 2011 

The nurse educator and nurse managers updated existing nursing competencies to 

ensure that the RN assessing the competency signed and dated each competency 

individually as required by the form. The nurse educator and nurse managers updated 

existing nursing competencies to indicate the method of verification (testing, 

demonstration, simulation, direct observation, record review, and employee feedback) 

was documented. Current compliance rate is 98 percent. Nurse managers monitor and 

report compliance in Nurse Leadership Committee monthly. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors Cathleen King, MHA, CRRN, Project Leader 

Maureen Washburn, RN, Team Leader 

Gayle Karamanos, MS, PA-C 

Larry Ross, MS 

Misti Kincaid, BS, Program Support Assistant 

Rachel Malone, Special Agent, Office of Investigations 

Ivan Martinez, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the West Texas VA Health Care System, Big Spring, TX 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southwest Health Care Network (10N18) 

Director, West Texas VA Health Care System (519/00) 

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: Jeff Bingaman, John Cornyn, Kay Bailey Hutchison, Tom Udall 

U.S. House of Representatives: Francisco Canseco, K. Michael Conaway, 

Randy Neugebauer, Steve Pearce, Silvestre Reyes 

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

VA OIG Office of Healthcare Inspections 20