Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02083-06 

Combined Assessment Program
 

Review of
 

VA Butler Healthcare
 

Butler, Pennsylvania
 

October 19, 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 VA Butler Healthcare, Butler, PA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CLC community living center 

EN enteral nutrition 

EOC environment of care 

facility VA Butler Healthcare 

FY fiscal year 

JC Joint Commission 

OIG Office of Inspector General 

PI performance improvement 

QM quality management 

RN registered nurse 

RRTP residential rehabilitation treatment program 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of VA Butler Healthcare, Butler, PA 

Table of Contents
 

Page 

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

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

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

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

Reported Accomplishments...................................................................................... 2
 

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

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

EOC................................................................................................................... 2
 

RN Competencies ............................................................................................. 3
 

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

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

EN Safety .......................................................................................................... 5
 

Management of Workplace Violence................................................................. 5
 

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

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

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys ................................................................................. 9
 

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 VA Butler Healthcare, Butler, PA
 

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 

seven activities. We made no 

recommendations in the following 

activities: 

	 Coordination of Care 

	 Enteral Nutrition Safety 

	 Management of Workplace Violence 

	 Physician Credentialing and 

Privileging 

	 Quality Management 

The facility’s reported accomplishments 

were the performance improvement 

reporting form and dashboards, which 

improved management and visualization 

of performance progress, and the 

Capital Asset Planning/Construction 

Project Team, which significantly 

improved project management and 

funding allocation. 

Recommendations: We made 

recommendations in the following two 

activities: 

Environment of Care: Ensure the facility 

designates community living center 

employees on all shifts to be fit tested 

and implements a process to 

periodically review this list and add 

employees as necessary to maintain 

appropriate numbers per shift. 

Registered Nurse Competencies: 

Establish a policy or process to identify 

a defined list of unit/position-specific 

competencies. Require competency 

validation documentation to be complete 

and current. Ensure core and 

unit/position-specific competency 

validation documentation specify the 

methods used to assess and validate 

competency. Require managers to 

specify the qualifications required for 

individuals who perform competency 

assessment and validation. 

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 VA Butler Healthcare, Butler, PA 

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 August 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 VA Butler 

Healthcare, Butler, Pennsylvania, Report No. 09-00517-97, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of VA Butler Healthcare, Butler, PA 

March 16, 2009). The facility had corrected all findings. 

(See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 135 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 Accomplishments
 PI Reporting Form	 The facility’s PI reporting form and dashboards have been 

standardized to display PI measurement progress at a 

glance using color codes of green (for met or exceeded 

compliance) and red (for non-compliance). Displays include 

target performance over a 3-year timeframe and a process 

owner. When a PI measure falls below target, the process 

owner completes a PI reporting form to address data 

analysis, conclusions, action plans, responsibility, 

implementation dates, and the evaluation of actions taken. 

Capital Asset	 The Capital Asset Planning/Construction Project Team was 

Planning/ formed in 2007 to systematically and strategically address 

capital improvements to	 and maintenance of the facility’s Construction 1940’s vintage campus. The team meets weekly and Project Team consists of the Associate Director; an interior designer; the 

Chiefs of Engineering, Contracting, and Environmental 

Management Services; and other staff. With this focused 

approach, the team has improved project management, 

communication, activity coordination, and allocation of the 

$12 million budget. 

Results 

Review Activities With Recommendations 

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 RRTPs complied with selected Mental 

Health RRTP requirements. 

We inspected the audiology, ophthalmology, podiatry, and 

dental departments and both CLC units. We also inspected 

VA OIG Office of Healthcare Inspections 2 
CAP Review of VA Butler Healthcare, Butler, PA 

Recommendation 

RN Competencies 

the Domiciliary Substance Abuse RRTP and Domiciliary 

Care Homeless Veteran RRTP units. The facility maintained 

a generally clean and safe environment. However, we 

identified the following area that needed improvement. 

Infection Control. If facilities use N95 respirators, the 

Occupational Safety and Health Administration requires that 

designated employees be fit tested annually. We reviewed 

15 employee training records and determined that all 

employees had the required annual fit testing. 

The CLC designated four to six employees per shift to be fit 

tested for the N95 respirator. However, on the list provided 

to the OIG, 5 of the 16 designated CLC employees no longer 

worked on that unit. Additionally, there was no process or 

plan to reevaluate the need to designate different employees 

and ensure that fit tested employees were available on all 

tours of duty to care for CLC residents in airborne isolation. 

1. We recommended that the facility designate CLC 

employees on all shifts to be fit tested and implement a 

process to periodically review this list and add employees as 

necessary to maintain appropriate numbers per shift. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies, 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 JC requires 

that clinical staff are deemed competent to perform their job 

responsibilities. A competency validation policy or process is 

required for staff who provide patient care, treatment, or 

services. Assessment and validation of competencies 

should be done when the RN is hired and then at least every 

3 years. The facility did not have a defined and effective RN 

competency validation policy or process. Although core 

competencies were identified, unit/position-specific 

competencies were not consistently identified. In addition, 

documentation of completed competencies was not 

consistently available. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of VA Butler Healthcare, Butler, PA 

Competency Validation Documentation. The JC requires 

that nursing personnel are competent to function in their 

assignments. 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 a CLC. We found that 8 of the 12 competency 

folders we reviewed had incomplete or missing validation 

documentation or outdated forms. 

Competency Validation Methods. The JC 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 for 

some competencies, validation methods were not specified 

for the skill being assessed and validated. 

Competency Validation by Qualified Individuals. The JC 

requires that competency is assessed and validated by an 

individual with the appropriate education, experience, or 

knowledge related to the skills being reviewed. Facility 

processes did not specify the qualifications required for 

individuals who perform competency assessment and 

validation. 

Recommendations	 2. We recommended that a policy or process be 

established to identify a defined list of unit/position-specific 

competencies. 

3. We recommended that processes be strengthened to 

ensure that competency validation documentation is 

complete and current. 

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

competency validation documentation specify the methods 

used to assess and validate competency. 

5. We recommended that managers specify the 

qualifications required for individuals who perform RN 

competency assessment and validation. 

Review Activities Without Recommendations
 

Coordination of 

Care 

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 

VA OIG Office of Healthcare Inspections 4 
CAP Review of VA Butler Healthcare, Butler, PA 

EN Safety
 

Management of 

Workplace 

Violence 

Physician C&P 

QM 

generally met VHA requirements. We made no 

recommendations. 

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’ electronic medical records. We also inspected 

areas where EN products were stored while conducting the 

EOC review, and we interviewed key employees. We 

determined that the facility generally met EN safety 

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 had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 12 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. 

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 

VA OIG Office of Healthcare Inspections 5 
CAP Review of VA Butler Healthcare, Butler, PA 

requirements, and senior managers supported the program. 

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 6 
CAP Review of VA Butler Healthcare, Butler, PA 

Appendix A 

Facility Profile1 

Type of Organization Independent outpatient clinic 

Complexity Level 3 

VISN 4 

Community Based Outpatient Clinics Cranberry Township, PA 

Ford City, PA 

Foxburg, PA 

Hermitage, PA 

New Castle, PA 

Veteran Population in Catchment Area 39,148 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial RRTP 66 

 CLC/Nursing Home Care Unit 60 

 Other 0 

Medical School Affiliation(s) none 

 Number of Residents 0 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

May 2011) 

$92 

Prior FY (2010) 

$96 

 Medical Care Expenditures $67 $70 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

593 

15,331 

N/A 

585 

18,486 

N/A 

o CLC/Nursing Home Care Unit 6,480 19,220 

Discharges 118 225 

Total Average Daily Census (including all bed 

types) 

68 112 

Cumulative Occupancy Rate (in percent) 41.7 69 

Outpatient Visits 87,350 141,620 

1 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of VA Butler Healthcare, Butler, PA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Ensure that the Contracting Officer’s 

Technical Representative conducts daily 

inspections of construction sites and that 

contractor oversight is documented. 

Daily oversight of construction sites 

was monitored successfully. The 

monitor was discontinued due to 

100 percent compliance, but the 

Contracting Officer's Technical 

Representatives continue to monitor. 

Y N 

2. Ensure that fire extinguisher signage 

complies with VA policy. 

New signage was purchased and 

installed. 

Y N 

Coordination of Care 

3. Ensure that discharge instructions are 

consistent with discharge summaries. 

Discharge summaries being congruent 

with discharge instructions was 

monitored successfully with 

100 percent compliance noted. 

Y N 

QM 

4. Ensure that contract physicians’ privileges 

do not extend beyond the length of the 

contract and that contracts are appropriately 

renewed. 

There is a main list of providers with 

contract dates indicated, which is used 

by the C&P Coordinator for tracking 

purposes. Each contract indicates the 

renewal dates for each site. The 

corresponding Medical Executive 

Committee minutes include the 

provider privileged at each site. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of VA Butler Healthcare, Butler, PA 

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 * 51.9 63.7 * 73.2 67.4 

VISN 64.2 60.1 61.8 63.6 63.9 59.2 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

* The facility does not provide inpatient care. 

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 9 
CAP Review of VA Butler Healthcare, Butler, PA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: October 5, 2011
 

From: Director, VISN 4, (10N4)
 

Subject: CAP Review of VA Butler Healthcare, Butler, PA
 

To: Director, Baltimore Office of Healthcare Inspections (54BA)
 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I have reviewed the submitted corrective actions and concur with the 

findings and recommendations. 

(original signed by:) 

MICHAEL E. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 10 
CAP Review of VA Butler Healthcare, Butler, PA 

Appendix E 

Acting Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: October 3, 2011 

From: Acting Director, VA Butler Healthcare (529/00) 

Subject: CAP Review of VA Butler Healthcare, Butler, PA 

To: Director, VISN 4 (10N4) 

Attached is our response to the CAP Review draft report from the survey 

conducted at VA Butler Healthcare the week of August 8, 2011. 

There is concurrence with all recommendations and corrective actions 

have been initiated. A follow up folder page and supporting documents 

have been uploaded to the Butler VA Healthcare SharePoint. 

Thank you for the opportunity to participate in this review. 

(original signed by:) 

SEAN H. NELSON 

Acting Medical Center Director 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Butler Healthcare, Butler, PA 

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 the facility designate CLC employees on 

all shifts to be fit tested and implement a process to periodically review this list and add 

employees as necessary to maintain appropriate numbers per shift. 

Concur. The Environmental Protection Specialist is responsible for the Respiratory 

Protection Program. The nurse managers will maintain a minimum of four staff 

members per shift from the Community Living Center to be included in the Respiratory 

Protection Program. The nurse managers will provide updates to the EPS when a 

respirator-qualified employee is permanently removed from the CLC. A replacement 

employee will be evaluated, trained, and fit tested within 30 days of assignment to the 

CLC. The Environmental Protection Specialist or designee will conduct quarterly audits 

to evaluate compliance. The results of this audit will be reported to the Environment of 

Care Committee for any required action/recommendation. 

N=Number of CLC staff who are fit tested 

D=Total number of CLC staff who require fit testing 

Target date for completion: December 1, 2011 

Recommendation 2. We recommended that a policy or process be established to 

identify a defined list of unit/position-specific competencies. 

Concur. The process for the identification of a defined list of unit/position specific 

competencies is that each nurse manager/supervisor is required to annually submit 

position-specific competencies to the Nurse Executive Council for approval. The 

approved list will be documented in the minutes of the Nurse Executive Council. A list 

of defined core competencies for all RN staff has been developed and outlined in the 

draft policy, “Evaluating Competency of Nursing Staff.” 

See VA Butler Healthcare OIG/CAP share point site for draft policy. 

Target Date for completion: November 1, 2011. 

Recommendation 3. We recommended that processes be strengthened to ensure that 

competency validation documentation is complete and current. 

Concur. Each nurse manager/supervisor is responsible for ensuring that the 

competency validation documentation is complete and specifies the method of 

verification, the date of validation, and the signature of the valuator and employee. This 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Butler Healthcare, Butler, PA 

is specified in the draft policy, “Evaluating Competency of Nursing Staff.” The Associate 

Director for Patient Care Services will monitor five RN competencies each quarter to 

assure that documentation is complete and current. The results of this audit will be 

reported to the Nurse Executive Committee. 

See Butler Healthcare OIG/CAP share point site for draft policy. 

N=Number of competencies that are complete/current 

D=Total number of competencies reviewed 

Target date for completion: November 1, 2011. 

Recommendation 4. We recommended that core and unit/position-specific 

competency validation documentation specify the methods used to assess and validate 

competency. 

Concur. The Competency Assessment Form will be used to identify each core 

competency and each unit-specific competency. The Competency Assessment Form 

requires completion of the verification method (observation, demonstration, 

verbalization, written, test/quiz, in-service, document review, simulation or other), 

educational intervention, and competency code. This is specified in the policy 

“Evaluating Competency of Nursing Staff.” 

See VA Butler Healthcare OIG/CAP share point site for draft policy 

Target date for completion: November 1, 2011. 

Recommendation 5. We recommended that managers specify the qualifications 

required for individuals who perform RN competency assessment and validation. 

Concur. As stated in the policy “Evaluating Competency of Nursing Staff,” “Competency 

validation will be completed by the unit nurse manager/supervisor or designee with the 

appropriate knowledge, education, and experience to confirm the required skill.” 

See VA Butler Healthcare OIG/CAP share point site for competency checklist 

document. 

Target date for completion: November 1, 2011. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of VA Butler Healthcare, Butler, PA 

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 Melanie Cool, LDN, Project Leader 

Frank Miller, PhD, Team Leader 

Donald Braman, RN 

Jennifer Christensen, DPM 

Judith Thomas, RN 

Sonia Whig, LDN 

Thomas Dominski, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 14 
CAP Review of VA Butler Healthcare, Butler, PA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VISN 4 (10N4) 

Acting Director, VA Butler Healthcare (529/00) 

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: Robert P. Casey, Jr.; Patrick J. Toomey 

U.S. House of Representatives: Jason Altmire, Mike Kelly, Mark Critz, 

Glenn W. Thompson 

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

VA OIG Office of Healthcare Inspections 15