Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02078-290 

Combined Assessment Program
 

Review of the
 

Lexington VA Medical Center
 

Lexington, Kentucky
 

September 27, 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 Lexington VA Medical Center, Lexington, KY 

Glossary 

ACLS Advanced Cardiac Life Support 

AD advance directive 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CLC community living center 

ED emergency department 

EN enteral nutrition 

EOC environment of care 

facility Lexington VA Medical Center 

FY fiscal year 

MEC Medical Executive Committee 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

PR peer review 

PTSD post-traumatic stress disorder 

QM quality management 

RRTP residential rehabilitation treatment program 

SA substance abuse 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

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

Physician C&P................................................................................................... 4
 

RN Competencies ............................................................................................. 4
 

EOC................................................................................................................... 5
 

Management of Workplace Violence................................................................. 6
 

EN Safety .......................................................................................................... 7
 

Coordination of Care ......................................................................................... 7
 

Review Activity Without Recommendations............................................................ 8
 

Medication Management ................................................................................... 8
 

Comments................................................................................................................... 8
 

Appendixes 

A. Facility Profile .................................................................................................... 9
 

B. Follow-Up on Previous Recommendations........................................................ 10
 

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

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 21
 

G. Report Distribution ............................................................................................ 22
 

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

Review of the Lexington VA Medical Center, 

Lexington, KY 

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 

eight activities. We made no 

recommendations in the following 

activity: 

 Medication Management 

The facility’s reported accomplishment 

was a reduction in length of stay and 

days of diversion in the emergency 

department. 

Recommendations: We made 

recommendations in the following seven 

activities: 

Quality Management: Report peer 

review findings to the Medical Executive 

Committee quarterly. Complete peer 

reviews within 120 days or have 

extensions. Perform and document 

pre-sedation risk assessments. Ensure 

providers who perform moderate 

sedation have documented evidence of 

Advanced Cardiac Life Support 

certification or equivalent training. 

Physician Credentialing and Privileging: 

Collect and maintain meaningful 

competency data. Ensure the Medical 

Executive Committee reviews data prior 

to making reprivileging decisions. 

Registered Nurse Competencies: 

Assess and validate competencies. 

Take action when competency does not 

meet expectations, and document 

actions. Specify the methods used to 

assess and validate competency. 

Environment of Care: Ensure Substance 

Abuse Residential Rehabilitation 

Treatment Program staff follow the 

medication destruction policy. Define a 

medication disposal protocol for the 

Post-Traumatic Stress Disorder 

Residential Rehabilitation Treatment 

Program, and monitor compliance. 

Management of Workplace Violence: 

Ensure managers comply with facility 

management of workplace violence 

policy. Revise the facility training plan. 

Enteral Nutrition Safety: Monitor 

compliance with use of the newly 

implemented enteral nutrition order set. 

Coordination of Care: Provide all 

components of written advance directive 

notification to patients, and document 

notification in the medical record. 

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 Lexington VA Medical Center, Lexington, KY 

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 eight activities: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through July 11, 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 Lexington VA Medical Center, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Lexington, Kentucky, Report No. 08-03074-101, 

March 31, 2009). (See Appendix B for further details.) The 

facility had repeat findings in the areas of Physician C&P 

(formerly included in the QM activity) and RN competencies. 

During this review, we also presented crime awareness 

briefings for 160 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishment
 ED Length of Stay 

and Diversion 

In 2010, the facility initiated a systems redesign project to 

reduce the time from ED discharge to admission to an 

inpatient unit thereby increasing access to ED beds. The 

project’s goals were to increase the availability of beds in the 

ED and to reduce the number of days patients were diverted 

to community hospitals. The facility implemented methods 

that improved the efficiency of the inpatient discharge 

process. This involved assigning utilization case managers 

to the medical teams to educate providers on utilization 

management criteria and to facilitate discharge readiness. 

The systems redesign team also streamlined the referral 

process for patients admitted to the CLC. As a result, the ED 

average length of stay deceased from greater than 11 hours 

between July 2009 and June 2010 to less than 8 hours 

between June 2010 and June 2011. The days of diversion 

during the same timeframes decreased from 42 days to 

4 days, respectively. 

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 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

documents. We identified the following areas that needed 

improvement. 

PR. VHA requires that PR results be reported to the MEC on 

a quarterly basis.1 VHA also requires that facilities complete 

a PR within 120 days from determination of the need for the 

review. Any extension beyond 120 days must be requested 

in writing from and approved by the facility’s Director. We 

found that PR findings were not discussed at the MEC in 

3 out of the past 4 quarters. Additionally, eight PRs were not 

completed within the 120-day timeframe, and no extension 

requests had been submitted. 

Moderate Sedation. VHA requires that a pre-sedation 

assessment that includes an assessment of risk be 

performed prior to administration of moderate sedation.2 

We reviewed the medical records of 10 patients who 

underwent moderate sedation and found that 5 had no 

documented evidence of risk assessments. 

VHA requires providers who perform moderate sedation to 

be trained in cardiopulmonary resuscitation, airway 

management, and management of cardiac arrhythmias.3 

This requirement may be satisfied by completing ACLS 

training or the equivalent. We reviewed the training records 

of seven non-anesthesia providers who performed moderate 

sedation in the Cardiac Catheterization Laboratory and found 

that three had no documented evidence of ACLS or Basic 

Life Support training. 

Recommendations	 1. We recommended that PR findings be reported to the 

MEC quarterly and that PRs are either completed within 

120 days or have extensions requested in writing from and 

approved by the facility’s Director. 

2. We recommended that processes be strengthened to 

ensure that pre-sedation risk assessments are consistently 

performed and documented prior to moderate sedation 

procedures. 

3. We recommended that all non-anesthesia providers who 

perform moderate sedation have documented evidence of 

ACLS certification or the equivalent in their training records. 

1 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 2 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 3 VHA Directive 2006-023. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

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

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 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. 

OPPE. VHA requires that data consistent with 

service-specific competency criteria be collected, maintained 

in each physician’s profile, and reviewed on an ongoing 

periodic basis.4 We reviewed 10 physician profiles for 

OPPE. Six of the 10 profiles reviewed did not have evidence 

of data for the previous 4 quarterly OPPE periods. This was 

a repeat finding from the previous CAP review. 

VHA requires that the MEC review and document clinical 

competence information prior to reprivileging.5 Although 

MEC meeting minutes stated that the committee reviewed 

OPPE data prior to reprivileging, there was no supporting 

data for 6 of the 10 physicians whose profiles we reviewed. 

Recommendation	 4. We recommended that service chiefs collect and 

maintain meaningful competency data for all providers and 

that the MEC review actual performance data prior to making 

reprivileging decisions. 

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 policy, interviewed nurse managers, and 

reviewed initial and ongoing competency assessment and 

validation documents for 12 RNs. We identified the following 

areas that needed improvement. 

Facility Competency Validation Process. The Joint 

Commission requires that clinical staff are deemed 

competent to perform their job responsibilities and that the 

facility takes action when staff competency does 

not meet expectations. While facility policy requires an 

initial assessment and validation of RN core and 

unit/position-specific competencies and an annual 

assessment thereafter, we found that managers did not 

4 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 5 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Recommendations 

EOC 

follow the policy. Core and unit/position-specific 

competencies were not consistently identified, assessed, or 

validated. Additionally, there was no evidence of actions 

taken to correct deficiencies. 

Competency Validation Documentation. The Joint 

Commission requires that nursing personnel are competent 

to perform their responsibilities. Core competencies, such as 

medication administration, are skills required for all RNs. 

Unit/position competencies are specific to a particular area of 

patient care, such as an intensive care unit. None of the 

12 RN competency folders contained sufficient evidence that 

core and unit/position-specific competencies had been 

validated. All of the folders had incomplete or missing 

validation documentation and outdated forms. This was a 

repeat finding from our previous CAP review. 

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. We 

found that validation methods were not specified for the skill 

being assessed and validated. 

5. We recommended that managers identify core and 

unit/position-specific RN competencies and that 

competencies are assessed and validated according to 

facility policy. 

6. We recommended that managers take appropriate 

action when staff competency does not meet expectations 

and document actions taken. 

7. We recommended that processes be strengthened to 

ensure that competency validation documentation is 

complete and current. 

8. We recommended that core and unit/position-specific 

competency validation documentation specify the methods 

used to assess and validate competency. 

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 SA and PTSD RRTPs were in compliance with 

selected Mental Health RRTP requirements. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Recommendations 

Management of 

Workplace 

Violence 

At the Cooper campus, we inspected the dental and primary 

care outpatient clinics; the ED; and the intensive care, locked 

mental health, and medical-surgical units. At the Leestown 

campus, we inspected the dental, women’s health, and 

primary care outpatient clinics; the CLC; and the SA and 

PTSD RRTPs. We found that the facility maintained a 

generally clean and safe environment. However, we 

identified the following conditions that needed improvement. 

Medication Security. Local policy requires that medications 

no longer being taken by a veteran in the SA RRTP be 

returned to pharmacy as soon as possible for destruction. 

We found that staff crushed the medications and mixed them 

with coffee grounds, which were disposed of in sharps 

containers. 

Additionally, local policy requires that staff in the PTSD 

RRTP follow the approved protocol for disposing of 

medications no longer used by veterans. However, the 

policy does not define a protocol. 

9. We recommended that staff in the SA RRTP follow the 

policy for the destruction of medications. 

10. We recommended that a protocol for disposal of 

medications in the PTSD RRTP be clearly defined and that 

compliance be monitored. 

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. We 

selected three assaults that occurred at the facility within the 

past 2 years, discussed them with managers, and reviewed 

applicable documents. We identified the following areas that 

needed improvement. 

Facility Policy. Local policy requires managers who receive 

a complaint of violence, threats, or harassment to investigate 

the complaint and complete an “Incident Documentation 

Form.” We found that managers did not complete the 

“Incident Documentation Form.” 

Training Plan. VHA requires that all staff working in the ED 

receive prevention and management of disruptive behavior 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Recommendations 

EN Safety 

Recommendation 

Coordination of 

Care 

training at orientation and annually.6 The facility training plan 

included prevention and management of disruptive behavior 

training for all employees during orientation but did not 

include annual refresher training for high-risk employees. 

11. We recommended that managers comply with all 

elements of the facility policy pertaining to management of 

workplace violence. 

12. We recommended that the facility training plan be 

revised to include annual refresher prevention and 

management of disruptive behavior training for all high-risk 

staff. 

The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. We also 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.7 We 

reviewed the medical records of 15 EN patients and found 

that 5 records did not contain all required information. For 

example, four records did not include physician orders for 

patient positioning and checking gastric residuals. Facility 

leaders implemented an order set in May 2011 that included 

all required elements. 

13. We recommended that compliance with the use of the 

newly implemented EN order set be monitored. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning and ADs in 

accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of AD 

notification, AD screening, and documentation of advance 

care planning discussions. We also reviewed the facility’s 

6 VHA Directive 2009-008 (also listed as 2010-008) Standards for Mental Health Coverage in Emergency
 

Departments and Urgent Care Clinics in VHA Facilities, February 22, 2010.
 7 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007.
 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

policy to determine whether it was consist with VHA policy. 

We identified the following area that needed improvement. 

AD Notification. VHA requires that patients receive written 

notification at each admission to a VHA inpatient facility 

stating their right to accept or refuse medical treatment, to 

designate a Health Care Agent, and to document their 

treatment preferences in an AD.8 As part of notification, 

patients must be informed that VA does not discriminate 

against patients based on whether or not they have an AD. 

We reviewed the medical records of 20 patients and found 

that 16 of the records did not contain evidence of all 

components of written notification. 

Recommendation	 14. We recommended that processes be strengthened to 

ensure that all components of written AD notification are 

provided to patients and that notification is documented in 

the medical record. 

Review Activity Without Recommendations
 

Medication 

Management 

The purpose of this review was to determine whether the 

facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. 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 14–20 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

8 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Appendix A 

Facility Profile9 

Type of Organization Tertiary care medical center 

Complexity Level 1c 

VISN 9 

Community Based Outpatient Clinics Berea, KY 

Hazard, KY 

Morehead, KY 

Somerset, KY 

Veteran Population in Catchment Area 90,658 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial RRTP 138 

 CLC/Nursing Home Care Unit 61 

Medical School Affiliation(s) University of Kentucky Medical Center 

 Number of Residents 83 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

March 2011) 

$219.5 

Prior FY (2010) 

$224.5 

 Medical Care Expenditures $113.5 $224.5 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,255.1 

31,466 

13,459 

1,274.6 

35,498 

28,577 

o CLC/Nursing Home Care Unit 9,345 19,680 

Hospital Discharges 3,582 7,385 

Total Average Daily Census (including all bed 

types) 

149.8 147 

Cumulative Occupancy Rate (in percent) 75 74 

Outpatient Visits 221,969 438,871 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

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 root cause analysis actions are 

monitored, measurable, and evaluated for 

effectiveness. 

An internal process was developed to 

ensure that root cause analysis actions 

are strong and that outcome measures 

are quantifiable, which allows 

managers to evaluate effectiveness. 

Y N 

2. Require that data on resuscitation events 

and outcomes is discussed, analyzed, and 

compared over time to identify opportunities 

for improvement. 

A critical care nurse specialist is 

responsible for maintaining the 

National Registry of Cardiopulmonary 

Resuscitation database and providing 

monthly reports to the Critical Care 

Committee. Oversight of the Critical 

Care Committee is now assigned to the 

Clinical Executive Council. 

Y N 

3. Ensure that medical records reviews are 

completed in accordance with VHA policy 

and that deficiencies are addressed. 

Reporting matrices were developed to 

summarize all ongoing point-of-care 

and medical record reviews. 

Point-of-care and medical records 

reviews have been added to the 

Medical Record Committee agenda 

template as monthly recurring report 

items. Findings, actions, and 

recommendations are reviewed and/or 

addressed by the Clinical Executive 

Council. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation 

Y/N 

4. Require that provider performance 

improvement data is collected, analyzed, 

and used to support decisions during the 

reprivileging process. 

Provider performance improvement 

data is part of the reprivileging process. 

Service level audits are done every 

6 months to assure compliance. 

N Y (see page 4) 

Coordination of Care 

5. Ensure discharge instructions, discharge 

summaries, and physician orders are 

consistent. 

A discharge summary template that 

imports the pharmacy note medication 

list was implemented in February 2011. 

Y N 

6. Require inter-facility transfer 

documentation to comply with VHA policy. 

The inter-facility transfer note template 

contains documentation of the 

availability of consent to transfer. 

Y N 

Nursing Competencies 

7. Develop a system to assure that all ED 

nursing staff competencies are evaluated 

and documented annually. 

Competencies are sent forward and 

filed with the annual nurse 

proficiencies. 

N Y (see page 5) 

Medication Management 

8. Require that nurses consistently document 

the effectiveness of all patient medications 

within the timeframe established by local 

policy. 

Effectiveness of as needed 

medications is reported quarterly to the 

Bar Code Medication Administration 

Committee. Compliance is at 

94 percent. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

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 61.9 57.6 58.1 62.3 59.6 62.6 

VISN 62.9 54.4 54.7 62.1 57.1 56.0 

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. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

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 13.74 11.18 19.72 22.79 27.56 17.33 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

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 13 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 September 7, 2011 

From:	 Director, VA Mid South Healthcare Network (10N9) 

Subject:	 CAP Review of the Lexington VA Medical Center, 

Lexington, KY 

To:	 Director, San Diego Office of Healthcare Inspections (54SD) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

1.	 I concur with the attached facility draft responses to the 

recommendations for improvement contained in the Combined 

Assessment Program Review of the Lexington VA Medical Center, 

Lexington, KY. 

2.	 If you have additional questions or concerns, please contact 

Tammy Williams, RN, VISN 9 Continuous Readiness Review 

Coordinator or Joseph Schoeck, VISN 9 Staff Assistant to the Network 

Director at 615-695-2200. 

(original signed by:) 

John Dandridge, Jr. 

Director, VA Mid South Healthcare Network (10N9) 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 30, 2011 

From: Director, Lexington VA Medical Center (596/00) 

Subject: CAP Review of 

Lexington, KY 

the Lexington VA Medical Center, 

To: Director, VA Mid South Healthcare Network (10N9) 

1.	 On behalf of the Lexington VA Medical Center, I would like to thank 

you for the opportunity to review the OIG report. I concur with the 

findings and recommendations. 

2.	 Included are our responses to the recommendations in the report. 

Although we have already been actively working on improvements, we 

appreciate the perspective from the OIG evaluation. We will take this 

opportunity to strengthen and improve our medical center. 

(original signed by:) 

DeWayne Hamlin 

Director, Lexington VA Medical Center 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

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 PR findings be reported to the MEC 

quarterly and that PRs are either completed within 120 days or have extensions 

requested in writing from and approved by the facility’s Director. 

Concur Target date for completion: Completed/ongoing 

The 4th Qtr FY10 and 1st Qtr FY11 PR reports were reviewed at the July 2011 Clinical 

Executive Board (CEB). Quarterly PR reports will be forward for CEB review by the 

second Wednesday of the month following the quarterly suspense. A tracking sheet 

has been implemented by the peer review committee. Elements of the peer review 

process are being tracked; including the number of days the peer review cases is open. 

Written extensions will be requested from the Director for all cases not meeting the 

120-day. 

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

pre-sedation risk assessments are consistently performed and documented prior to 

moderate sedation procedures. 

Concur Target date for completion: September 30, 2011 

The documentation process within specific services did not facilitate completion of the 

pre-sedation risk assessment. The Interventional Radiology documentation system has 

been revised to include an area for the assignment of the ASA. In Cath Lab when the 

pre-procedure note by cardiologists, which documents the ASA, is not used then the 

front page of the moderate sedation purple sheet area that includes the ASA 

assignment will be completed by physician and attached to MAC-lab document for vista 

imaging. This has been implemented. In Bronchoscopy physicians fill out the moderate 

sedation purple sheet with ASA. Proposed revision to Moderate Sedation Policy for 

Non-Anesthesia providers will require all physician documentation, including ASA, to be 

completed prior to any sedation medications being administered. 

Recommendation 3. We recommended that all non-anesthesia providers who perform 

moderate sedation have documented evidence of ACLS certification or the equivalent in 

their training records. 

Concur Target date for completion: September 30, 2011 

The providers without ACLS were cardiologists. The Moderate Sedation policy will be 

revised to state, “Cardiologists and cardiology fellows have equivalent (actually much 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

more extensive) training and are exempt from the ACLS requirement.” They still must 

take the “Moderate Sedation National Training Program.” 

Recommendation 4. We recommended that service chiefs collect and maintain 

meaningful competency data for all providers and that the MEC review actual 

performance data prior to making reprivileging decisions. 

Concur Target date for completion: November 1, 2011 

The medical center policy will be revised to include information to clarify what types of 

data are meaningful criteria for use in OPPE. The service chiefs and key staff will be 

educated regarding the types of data to use and service level criteria will be revised for 

those services found to be deficient and the new criteria approved by the MEC. The 

actual reprivileging data will be filed in the OPPE folder and the folder presented to 

Medical Executive Council at the time of reprivileging. 

Recommendation 5. We recommended that managers identify core and 

unit/position-specific RN competencies and that competencies are assessed and 

validated according to facility policy. 

Concur Target date for completion: April 30, 2012 

Core and unit/position-specific RN competences have been identified. The proficiency 

competency will be formatted to match the indentified competencies per unit by 

October 1, 2011. Assessment and validation will be completed at orientation and in the 

annual competency fair (January–April). Just in time competency assessment and 

validation will be done as need arises. 

Recommendation 6. We recommended that managers take appropriate action when 

staff competency does not meet expectations and document actions taken. 

Concur Target date for completion: April 30, 2012 

With the use of an annual competency fair during the same time each year (Jan thru 

April), those who are unable to demonstrate competency will receive retraining. If 

competency is not achieved appropriate action will be under taken. Actions taken to 

achieve competency will be documented in the staff member’s competency folder. 

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

competency validation documentation is complete and current. 

Concur Target date for completion: April 30, 2012 

During the annual competency fair completion will be monitored 

(numerator/denominator) to ensure 100% compliance. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Recommendation 8. We recommended that core and unit/position-specific 

competency validation documentation specify the methods used to assess and validate 

competency. 

Concur Target date for completion: Completed 

Proficiency competency forms have been revised to add core and unit/position-specific 

method used to assess and validate competency. 

Recommendation 9. We recommended that staff in the SA RRTP follow the policy for 

the destruction of medications. 

Concur Target date for completion: September 30, 2011 

Green Environmental Management System (GEMS) Pharmaceutical Waste program is 

being implemented in the Substance Abuse and PTSD Residential Rehabilitation 

Treatment Program. All excess/discontinued medication with the exception of 

controlled substances and liquids will be disposed of in the Pharmaceutical Waste 

containers. Controlled substances and liquid medications will be returned to pharmacy. 

100% of staff has been trained on the process. We are awaiting arrival of the 

Pharmaceutical waste containers. Full implementation will be completed 

September 23, 2011. Compliance with the process will be monitored daily on 

Residential Rehabilitation Treatment Program Rounds Checklist. Monitoring will 

continue until compliance is 95% for 4 months. 

Recommendation 10. We recommended that a protocol for disposal of medications in 

the PTSD RRTP be clearly defined and that compliance be monitored. 

Concur Target date for completion: September 30, 2011 

Green Environmental Management System (GEMS) Pharmaceutical Waste program is 

being implemented in the Substance Abuse and PTSD Residential Rehabilitation 

Treatment Program. All excess/discontinued medication with the exception of 

controlled substances and liquids will be disposed of in the Pharmaceutical Waste 

containers. Controlled substances and liquid medications will be returned to pharmacy. 

100% of staff has been trained on the process. We are awaiting arrival of the 

Pharmaceutical waste containers. Full implementation will be completed 

September 23, 2011. Compliance with the process will be monitored daily on 

Residential Rehabilitation Treatment Program Rounds Checklist. Monitoring will 

continue until compliance is 95% for 4 months. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Recommendation 11. We recommended that managers comply with all elements of 

the facility policy pertaining to management of workplace violence. 

Concur Target date for completion: Completed 

The facility policy “Workplace Violence Prevention” 07B-10 was revised to match 

current practice. The “Incident Documentation Form” was removed, and replaced with: 

“The supervisor/manager will immediately notify the VA Police.” 

Recommendation 12. We recommended that the facility training plan be revised to 

include annual refresher prevention and management of disruptive behavior training for 

all high-risk staff. 

Concur Target date for completion: Completed 

The revised policy “Workplace Violence Prevention” 07B-10 now includes a training 

outline for all employees as follows: 

(1) Level I training – web based, due annually, and required for all staff. 

(2) Level II training – in addition to the web based training, a 4 hour slide show 

presentation, required for employees dealing with customers but otherwise low 

risk. 

(3) Level III training – all of the above training plus 4 hours of personal safety 

skills, required for employees in moderate risk areas. 

(4) Level IV training – all of the above training plus 4 hours of therapeutic 

containment, required for employees in high risk areas. 

The areas considered to be low risk, moderate risk and high risk are to be determined 

by the Prevention and Management of Disruptive Behavior (PMDB) coordinator. 

Recommendation 13. We recommended that compliance with the use of the newly 

implemented EN order set be monitored. 

Concur Target date for completion: September 1, 2011 

Clinical Nutrition will implement a monitor on September 1 to track use of the Inpatient 

EN Order Set. The medical record of each new tube fed inpatient and Community 

Living Center (CLC) resident will be reviewed for use of this order set. If it is not used, 

the responsible dietitian will follow-up with the provider who wrote the order and provide 

education or assistance as needed. Monitoring of each area will continue until areas 

are at 95% compliance for 4 months. 

Recommendation 14. We recommended that processes be strengthened to ensure 

that all components of written AD notification are provided to patients and that 

notification is documented in the medical record. 

Concur Target date of completion: Completed/ongoing 

Staff were required to review the VHA, Lexington Facility and Health Administration 

Service Directive/Memorandums on Advance Health Care Planning. Staff reviewed the 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

“Admission Advanced Directive Progress Note” template and were required to sign their 

understanding of the required fields in the template. The template includes 

documentation of the patient receiving all AD notification materials. Weekly audit to 

ensure compliance with AD screening at the time of admission has been implemented. 

Exceptions will be reported to staff on a weekly basis. Report will be shared with: Chief, 

HAS, Assistant Chief, HAS and Chief, AC&P, Supervisor, Patient Support Unit. Once 

95% compliance has been achieved for 3 consecutive months, auditing will be provided 

on a monthly basis. 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

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	 Deborah Howard, RN, Project Leader 

Elizabeth Burns, MSSW, Team Leader 

Dorothy Duncan, RN 

Stephanie Hills, RN 

Sandra Khan, RN 

Judy Montano, MS 

Kathleen Shimoda, RN 

Derrick Hudson, Program Support Assistant 

Brian Celatka, Office of Investigations 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the Lexington VA Medical Center, Lexington, KY 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N9) 

Director, Lexington VA Medical Center (596/00) 

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: Mitch McConnell, Rand Paul 

U.S. House of Representatives: Ben Chandler 

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

VA OIG Office of Healthcare Inspections 22