Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02085-10 

Combined Assessment Program
 

Review of the
 

Veterans Health Care System
 

of the Ozarks
 

Fayetteville, Arkansas
 

October 26, 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 Veterans Health Care System of the Ozarks, Fayetteville, AR 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

EN enteral nutrition 

EOC environment of care 

facility Veterans Health Care System of the Ozarks 

FY fiscal year 

IC infection control 

OIG Office of Inspector General 

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 Veterans Health Care System of the Ozarks, Fayetteville, AR 

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
 

EN Safety .......................................................................................................... 2
 

EOC................................................................................................................... 3
 

Review Activities Without Recommendations ......................................................... 4
 

Coordination of Care ......................................................................................... 4
 

Management of Workplace Violence................................................................. 4
 

Medication Management ................................................................................... 4
 

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

QM..................................................................................................................... 5
 

RN Competencies ............................................................................................. 5
 

Comments................................................................................................................... 5
 

Appendixes 

A. Facility Profile .................................................................................................... 6
 

B. Follow-Up on Previous Recommendation ......................................................... 7
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 8
 

D. VISN Director Comments .................................................................................. 10
 

E. Acting Facility Director Comments..................................................................... 11
 

F. OIG Contact and Staff Acknowledgments ......................................................... 14
 

G. Report Distribution ............................................................................................ 15
 

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

Review of the Veterans Health Care System of the Ozarks, 

Fayetteville, AR 

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 

August 8, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

	 Coordination of Care 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

	 Quality Management 

	 Registered Nurse Competencies 

The facility’s reported accomplishment 

was improved accuracy of patient 

identification. 

Recommendations: We made 

recommendations in the following two 

activities: 

Enteral Nutrition Safety: Revise facility 

enteral nutrition and infection control 

policies, and monitor compliance with 

the updated policies. Ensure enteral 

nutrition documentation includes all 

required elements. 

Environment of Care: Ensure 

designated staff complete annual 

N95 respirator fit testing, and monitor 

compliance. 

Comments 

The Veterans Integrated Service 

Network and Acting 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 Veterans Health Care System of the Ozarks, Fayetteville, AR 

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 August 12, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on a recommendation from 

our prior CAP review of the facility (Combined Assessment 

Program Review of the Veterans Health Care System of the 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Ozarks, Fayetteville, Arkansas, Report No. 08-02643-42, 

December 11, 2008). The facility had corrected the finding. 

(See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 93 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
 Improved Accuracy 

of Patient 

Identification 

Facility staff consider correct patient identification to be vital 

for providing safe patient care. Staff implemented the use of 

identification bracelets for inpatients and outpatients that 

include a picture of the patient. The picture improves patient 

identification by decreasing errors when two patients have 

the same or similar names or when a patient is unable to 

verbalize his or her name. 

Results 

Review Activities With Recommendations 

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. 

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 areas that needed improvement. 

Policy. VHA requires x-ray confirmation of nasogastric tube 

placement prior to using the tube for EN feedings.1 Three of 

the four local policies related to EN did not require x-ray 

verification of tube placement prior to using the tube for EN 

feedings. 

1 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Recommendations 

EOC 

Recommendation 

VHA also requires that facility IC policy address EN.2 We 

reviewed facility IC policy and determined that it did not 

address IC expectations for EN, such as swabbing the tops 

of EN cans with alcohol wipes before pouring contents into 

feeding bags. 

EN Documentation. VHA requires that staff document 

specific EN information in patients’ medical records.3 We 

reviewed the medical records of five EN patients and found 

that four records did not contain all required information, 

such as checking gastric residual or properly positioning the 

patient. 

1. We recommended that facility policies related to EN be 

updated to be consistent with VHA policy, that facility IC 

policy be revised to include EN IC expectations, and that 

compliance with the updated policies be monitored. 

2. We recommended that processes be strengthened to 

ensure that EN documentation includes all required 

elements. 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected inpatient units (medical/surgical, intensive 

care, step-down, and mental health), the emergency 

department, the same day surgery/post-anesthesia care unit, 

and outpatient clinics. The facility maintained a generally 

clean and safe environment. However, we identified the 

following condition that needed improvement. 

IC. If facilities use N95 respirators, the Occupational Safety 

and Health Administration requires that designated 

employees are fit tested annually. We reviewed 

20 employee training records and determined that 

4 designated employees did not have the required annual fit 

testing. 

3. We recommended that annual N95 respirator fit testing 

be completed and that compliance be monitored. 

2 VHA Handbook 1109.05. 

3 VHA Handbook 1109.05. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Review Activities Without Recommendations
 

Coordination of 

Care 

Management of 

Workplace 

Violence 

Medication 

Management 

Physician C&P 

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 

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. 

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. 

The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. We made no 

recommendations. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

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. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

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 RNs. We determined that the 

facility had established an effective process to ensure that 

RN competencies were assessed and validated and that 

actions were taken when deficiencies were identified. We 

made no recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 10–13 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Appendix A 

Facility Profile4 

Type of Organization Medical center 

Complexity Level 2 

VISN 16 

Community Based Outpatient Clinics Branson, MO 

Fort Smith, MO 

Harrison, AR 

Jay, OK 

Mount Vernon, MO 

Ozark, AR 

Veteran Population in Catchment Area 128,658 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

71 

 Community Living Center/Nursing 

Home Care Unit 

N/A 

 Other 0 

Medical School Affiliation(s) University of Arkansas for Medical Sciences 

Area Health Education Center-Northwest 

University of Arkansas for Medical 

Sciences, Little Rock 

 Number of Residents 1.5 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

March 2011) 

$245 

Prior FY (2010) 

$236 

 Medical Care Expenditures $98 $236 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,203.1 

47,985 

7,646 

1,180.5 

53,168 

15,749 

o Community Living 

Center/Nursing Home Care Unit 

0 0 

Hospital Discharges 1,620 3,522 

Total Average Daily Census (including all bed 

types) 

57 43 

Cumulative Occupancy Rate (in percent) 59.7 62.3 

Outpatient Visits 257,341 509,819 

4 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Appendix B 

Follow-Up on Previous Recommendation 

Recommendation Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Require that the Information Security 

Officer or his/her designee participates in 

environmental rounds and that documentation 

of participation is complete. 

The Information Security Officer is now 

a permanent member of the team 

conducting environmental rounds, and 

facility policy has been amended to 

reflect the change. Compliance is as 

follows: 

FY 2010 (March–September) = 71% 

FY 2011 (October–June) = 91% 

Y N 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

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 64.5 60.9 69.7 61.8 63.2 

VISN 62.4 54.6 50.8 65.3 52.4 53.2 

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 8 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

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

conditions5 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 2007–2010. 

Table 2 

Mortality Readmission 

Heart Attack Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 12.67 8.83 15.16 * 20.68 14.59 

VHA 12.54 9.24 12.02 12.99 19.66 15.15 

* Not enough cases 

5 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 9 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 October 11, 2011 

From:	 Director, South Central VA Health Care Network (10N16) 

Subject:	 CAP Review of the Veterans Health Care System of the 

Ozarks, Fayetteville, AR 

To:	 Director, Kansas City Office of Healthcare Inspections 

(54KC) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

1. Attached is the Veterans Health Care Systems of the Ozarks response 

to the August CAP Draft Report. I have reviewed the report and concur 

with the responses. 

2. If you have any questions regarding the report, contact Mary Jones, 

HSS at 601-206-6974. 

George H. Gray, Jr. 

Network Director VISN 16 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Appendix E 

Acting Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 October 7, 2011 

From:	 Acting Director, Veterans Health Care System of the Ozarks 

(564/00) 

Subject:	 CAP Review of the Veterans Health Care System of the 

Ozarks, Fayetteville, AR 

To:	 Director, South Central VA Health Care Network (10N16) 

Attached is the Veterans Health Care Systems of the Ozarks response to 

the August CAP Draft Report. 

(original signed by:) 

John Henley, MD 

Acting Medical Center Director 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Comments to Office of Inspector General’s Report
 

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

recommendations in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that facility policies related to EN be updated 

to be consistent with VHA policy, that facility IC policy be revised to include EN IC 

expectations, and that compliance with the updated policies be monitored. 

Concur 

Target date for completion: December 30, 2011 

An interdisciplinary team is updating current policies to reflect the OIG 

recommendations and VHA policy. Infection Control practice is being incorporated in 

the updated policy. 

The Chief, Nutrition and Food Services and Nurse Educator will report compliance data 

monthly to Clinical Executive Board. 

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

EN documentation includes all required elements. 

Concur 

Target date for completion: December 30, 2011 

An interdisciplinary team is reviewing and updating documentation templates associated 

with EN to include all required elements. Staff training is to be completed by 

January 15, 2012. 

The Chief, Nutrition and Food Services and Nurse Educator will report compliance data 

monthly to Clinical Executive Board. 

Recommendation 3. We recommended that annual N95 respirator fit testing be 

completed and that compliance be monitored. 

Concur 

Target date for completion: November 30, 2011 

To further improve the 60% annual fit test compliance rate found during the 

assessment, the facility will implement the following: Safety, Emergency & Operations 

Management Service (SEOM) will establish an internal process for removing staff from 

the N95 Respirator database during the clearance process through SEOM. SEOM will 

report to facility leadership through the EOC committee monthly on any Service with 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

staff who are delinquent in annual re-testing. Each Service having employees requiring 

N95 respirator use will maintain the status of their employee’s compliance with the 

N95 respiratory protection program. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

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	 Dorothy Duncan, RN, MHA, Project Leader 

Laura Tovar, LCSW, Team Leader 

Jennifer Kubiak, RN, CPHQ 

James Seitz, RN, MBA 

Jennifer Whitehead, Program Support Assistant 

Wessley Dumas, Office of Investigations 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Veterans Health Care System of the Ozarks, Fayetteville, AR 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, South Central VA Health Care Network (10N16) 

Acting Director, Veterans Health Care System of the Ozarks (564/00) 

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: Roy Blunt, John Boozman, Tom Coburn, James M. Inhofe, 

Claire McCaskill, Mark L. Pryor 

U.S. House of Representatives: Dan Boren, Russ Carnahan, Jo Ann Emerson, 

Billy Long, Steve Womack, 

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

VA OIG Office of Healthcare Inspections 15