Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02086-28 

Combined Assessment Program
 

Review of the
 

VA Central Iowa Health Care System
 

Des Moines, Iowa
 

November 17, 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 VA Central Iowa Health Care System, Des Moines, IA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CPR cardiopulmonary resuscitation 

CS controlled substances 

EN enteral nutrition 

EOC environment of care 

facility VA Central Iowa Health Care System 

FY fiscal year 

MH mental health 

OIG Office of Inspector General 

PR peer review 

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 VA Central Iowa Health Care System, Des Moines, IA 

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 ............................................................................................. 5
 

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

EOC................................................................................................................... 6
 

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

Review Activities Without Recommendations ......................................................... 8
 

EN Safety .......................................................................................................... 8
 

Medication Management ................................................................................... 9
 

Comments................................................................................................................... 9
 

Appendixes 

A. Facility Profile .................................................................................................... 10
 

B. Follow-Up on Previous Recommendations........................................................ 11
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 15
 

D. VISN Director Comments .................................................................................. 17
 

E. Facility Director Comments ............................................................................... 18
 

F. OIG Contact and Staff Acknowledgments ......................................................... 24
 

G. Report Distribution ............................................................................................ 25
 

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

Review of the VA Central Iowa Health Care System,
 

Des Moines, IA
 

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: 

 Enteral Nutrition Safety 

 Medication Management 

The facility’s reported accomplishment 

was increased hiring of veterans and 

employees with disabilities. 

Recommendations: We made 

recommendations in the following six 

activities: 

Quality Management: Ensure peer 

review extensions are requested in 

writing. Require reviews of current 

medications to be completed and 

documented in the required timeframe. 

Ensure results of medical record quality 

reviews are reported at least quarterly. 

Require employees to maintain current 

cardiopulmonary resuscitation 

certification. 

Physician Credentialing and Privileging: 

Require that competency criteria be 

service-specific and that data be 

collected and reviewed during the 

reprivileging process. Ensure clinical 

privileges granted are appropriate to the 

provider’s training and experience. 

Registered Nurse Competencies: 

Ensure competency validation 

documentation is complete and legible. 

Complete the facility-wide nursing 

competency audit, and initiate corrective 

actions as needed. 

Management of Workplace Violence: 

Update and strengthen the current 

workplace violence policy. Complete 

brief incident reports for all assaults 

involving patients. Discuss behavioral 

record flag placements with patients, 

and document the discussions. 

Environment of Care: Complete annual 

N95 respirator fit testing, and monitor 

compliance. Secure all Veterans 

Canteen Service retail storage rooms. 

Coordination of Care: Provide all 

components of written advance directive 

notification to patients, and document 

notification. Accurately document 

patient advance directive screening. 

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 VA Central Iowa Health Care System, Des Moines, IA 

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 8, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on selected recommendations 

from our prior CAP review of the facility (Combined 

Assessment Program Review of the VA Central Iowa Health 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Care System, Des Moines, Iowa, Report No. 08-02597-63, 

February 3, 2009). (See Appendix B for further details.) The 

facility had repeat findings in QM and EOC from our previous 

review. 

During this review, we also presented crime awareness 

briefings for 48 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
 Increased Hiring of 

Veterans and 

Employees with 

Disabilities 

In support of meeting employment goals, the facility’s Human 

Resource Department concluded that a new way of 

recruiting applicants in targeted areas had to be developed 

and embraced. In April 2010, the facility hosted a 

collaborative learning session for community partners to 

develop the process and phase approach for recruitment. 

Phase I focused on recruiting specific high turnover positions 

through internal and direct hire authorities prior to external 

advertising. Phase II focused on recruitment of specialized 

or difficult to recruit positions. 

The results were an increase in hiring of veteran employees 

by 2.9 percent and an increase in hiring of employees with 

disabilities by 0.63 percent. 

Results 

Review Activities With Recommendations 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance 

with applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

PR. VHA policy requires facilities to complete a PR within 

120 days.1 Any extension beyond 120 days must be 

requested in writing from and approved by the facility’s 

Director. Seven of the 13 PRs that exceeded 120 days did 

not have the required written request and approval for 

extension. 

Moderate Sedation. VHA requires that providers document 

a review of current medications within 30 days prior to a 

procedure where moderate sedation will be used.2 We 

reviewed the medical records of 10 patients who had 

selected procedures where moderate sedation was used. 

We found that seven of the records had incomplete or 

missing documentation of a review of current medications. 

Medical Record Review. VHA requires that the results of 

medical records reviewed on an ongoing basis at the point of 

care be reported at least quarterly to the facility medical 

record review committee.3 We found that the results of 

these record reviews were not reported to the Medical 

Records Committee. 

CPR Certification. Facility policy requires identified staff to 

maintain current CPR certification. We reviewed the status 

of the 307 employees required to have CPR certification and 

found that 23 (7 percent) did not have current certification at 

the time of our inspection. This was a repeat finding from 

the previous CAP review. 

Facility policy states that staff who do not maintain current 

CPR certification will be removed from direct patient care 

responsibilities. The facility was not in compliance with this 

policy at the time of our inspection. Twenty-two of the 

23 employees with expired CPR certification were providing 

direct patient care. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that PR extensions are requested in writing from and 

approved by the facility’s Director. 

2. We recommended that processes be strengthened to 

ensure that reviews of current medications are completed 

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 Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

and documented in the required timeframe prior to 

procedures requiring moderate sedation. 

3. We recommended that medical record review processes 

be strengthened to ensure that results of all medical record 

quality reviews are reported at least quarterly to the Medical 

Records Committee. 

4. We recommended that processes be strengthened to 

ensure that employees maintain current CPR certification 

and that the action required by facility policy is taken when 

employees do not maintain certification. 

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 areas that needed improvement. 

Ongoing Professional Practice Evaluation. 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 The facility had 

implemented a policy that specified the performance data 

that would be collected, compiled, and considered during the 

reprivileging process. 

We found that some criteria were not service-specific and 

that data collected did not meet the requirements of facility 

policy. For example, the percentage of discharge 

summaries completed within 24 hours was being measured 

for providers who did not admit or discharge patients. In 

addition, some facility required service-level data was not 

collected. 

Clinical Privileges. VHA requires that providers possess the 

appropriate training and experience to justify requested 

clinical privileges.5 For five physicians, we found that 

privileges were approved that were not appropriate for their 

training and experience. For example, one emergency 

department and four primary care providers were privileged 

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 VA Central Iowa Health Care System, Des Moines, IA 

Recommendations 

RN Competencies 

Recommendations 

to provide MH services that they did not have the appropriate 

education or experience to provide. 

5. We recommended that competency criteria be 

service-specific and that data be collected and reviewed 

during the reprivileging process in accordance with facility 

policy. 

6. We recommended that processes be strengthened to 

ensure that clinical privileges granted are appropriate to the 

providers’ training and experience. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies and processes, interviewed 

nurse managers, and reviewed initial and ongoing 

competency assessment and validation documents for 

12 RNs. We identified the following area that needed 

improvement. 

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 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-specific competencies had been validated. 

All 12 folders had incomplete or illegible validation 

documentation. 

During this review, management discovered that five 

competency assessments had been inappropriately signed. 

A facility-wide audit of nursing competencies has been 

initiated. 

7. We recommended that processes be strengthened to 

ensure that competency validation documentation is 

complete and legible. 

8. We recommended that management complete the 

facility-wide nursing competency audit and initiate corrective 

actions as needed based on the audit results. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Management of 

Workplace 

Violence 

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 policies 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. The Occupational Safety and Health 

Administration require facilities to have a comprehensive 

written workplace violence policy. The facility’s Workplace 

Violence Prevention Program policy was not current or 

comprehensive. 

Management of Incident. The facility’s Patient Safety 

Program policy requires all assaults involving patients to be 

reported electronically within 24 hours using the brief 

incident report system. We reviewed documentation of a 

patient-to-staff assault and did not find a brief incident report. 

Patient Notification. When a patient’s record is flagged for a 

behavioral problem, the Disruptive Behavior Committee 

charter requires that the patient’s treatment team discuss the 

assault incident with the patient. We reviewed a medical 

record that had a behavioral patient record flag and did not 

find documentation that the treatment team discussed the 

action with the patient. 

9. We recommended that the facility update and 

strengthen the current workplace violence policy to include 

detailed guidance for managing violent incidents involving 

patients, employees, and visitors. 

10. We recommended that processes be strengthened to 

ensure that brief incident reports are completed for all 

assaults involving patients. 

11. We recommended that processes be strengthened to 

ensure that when a patient’s record is flagged for a 

behavioral problem, the treatment team discusses the 

assault incident with the patient and documents the 

discussion in the medical record. 

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 

EOC
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

facility’s domiciliary was in compliance with selected MH 

Residential Rehabilitation Treatment Program requirements. 

We inspected selected inpatient (medical-surgical, acute 

MH, intensive care, community living center) units, the 

domiciliary, and the same day surgery and post-anesthesia 

care units. We also inspected the emergency department 

and the dental, primary care, and outpatient physical therapy 

clinics. The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement. 

Infection Control. If facilities use N95 respirators, the 

Occupational Safety and Health Administration requires that 

designated employees are fit tested annually. We reviewed 

23 employee records and determined that 12 designated 

employees did not have the required annual fit testing. 

Security. Unsecured doors to Veterans Canteen Service 

retail storage rooms allow unauthorized access to food and 

merchandise. During our inspection, we found three out of 

the four storage rooms unlocked, and one of the doors was 

ajar. Only one storage room had an automatic lock installed. 

This was a repeat finding from the previous CAP review. 

Recommendation	 12. We recommended that annual N95 respirator fit testing 

be completed for all designated employees and that 

compliance be monitored. 

13. We recommended that processes be strengthened to 

ensure that Veterans Canteen Service retail storage rooms 

are secured at all times. 

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 for evidence of 

advance directive notification, advance directive screening, 

and documentation of advance care planning discussions. 

We also reviewed the facility’s policy to determine whether it 

was consistent with VHA policy. We identified the following 

areas that needed improvement. 

Advance Directive Notification. VHA requires that patients 

receive written notification at each admission to a VHA 

facility regarding their right to accept or refuse medical 

treatment, to designate a Health Care Agent, and to 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

document their treatment preferences in an advance 

directive.6 As part of notification, patients must be informed 

that VA does not discriminate based on whether or not they 

have an advance directive. We reviewed the medical 

records of 20 patients and found that 19 of the records did 

not contain evidence of all components of written notification. 

Advance Directive Screening Accuracy. VHA requires that 

staff screen patients at each admission to a VHA facility to 

determine whether they have an advance directive and 

document the screening in the medical record.7 Although 

advance directive screenings were completed for 19 of the 

20 patients whose medical records we reviewed, 3 of the 

screenings were not accurate. Two screenings documented 

that there were no advance directives; however, we located 

advance directives for both patients in the electronic medical 

records. One screening documented that there was an 

advance directive; however, we did not locate an advance 

directive in the electronic medical record. 

Recommendations	 14. We recommended that processes be strengthened to 

ensure that all components of written advance directive 

notification are provided to patients and that notification is 

documented in the medical record. 

15. We recommended that processes be strengthened to 

ensure that patient advance directive screening is accurately 

documented in the medical record. 

Review Activities Without 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 determined that the 

facility generally met EN safety requirements. We made no 

recommendations. 

6 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 7 VHA Handbook 1004.02. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

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 17–23 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 9 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Appendix A 

Facility Profile8 

Type of Organization General medical/surgical, acute psychiatry, 

long-term care, and domiciliary 

Complexity Level 2 

VISN 23 

Community Based Outpatient Clinics Mason City, IA 

Marshalltown, IA 

Fort Dodge, IA 

Carroll, IA 

Knoxville, IA 

Veteran Population in Catchment Area 90,599 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

77 hospital 

60 domiciliary 

 Community Living Center/Nursing 

Home Care Unit 

140 

Medical School Affiliation(s) University of Iowa College of Medicine 

Des Moines Area Medical Education 

Consortium, Inc. 

Des Moines University 

 Number of Residents 21 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

March 2011) 

$195.9 

Prior FY (2010) 

$187.6 

 Medical Care Expenditures $69.4 $187.6 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,323 

25,727 

6,214 

1,294 

31,834 

12,077 

o Community Living 

Center/Nursing Home Care Unit 

22,229 41,213 

Hospital Discharges 1,171 2,379 

Total Average Daily Census (including all bed 

types) 

156 146 

Cumulative Occupancy Rate (in percent) 44.3 43.0 

Outpatient Visits 146,560 284,128 

8 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

C&P 

1. Collect and consider provider-specific 

performance improvement data during 

reprivileging, in accordance with VHA policy. 

Provider-specific performance 

improvement criteria is collected and 

considered during the reprivileging 

process in accordance with VHA 

policy. 

Y N 

QM 

2. Require employees to complete CPR 

training in accordance with facility policy. 

The CPR training database was 

updated to ensure alignment with 

policy and is monitored quarterly by 

Education Service. Additional CPR 

training opportunities were scheduled. 

Education Service monitors staff 

compliance with training and notifies 

supervisors/managers of 

delinquencies. Managers are to initiate 

corrective action when an employee’s 

CPR training is delinquent. 

N Y (see pages 3–4) 

3. Establish a committee to provide 

oversight and coordination of the medical 

record review process. 

The facility chartered a Medical 

Records Committee, and the first 

committee meeting was held 

February 11, 2009. The committee 

has met regularly since its inception 

and is responsible for oversight and 

coordination of the medical record 

review process. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

4. Correct identified safety, infection control, 

and patient privacy deficiencies. 

Identified safety, infection control, and 

patient privacy deficiencies were 

corrected. 

N Y (see page 7) 

5. Require consultation responses to be 

completed within the facility’s established 

timeframe. 

Managers developed a consistent 

process to ensure that all inpatient 

consults are seen and that 

documentation is completed within 

established timeframes. 

Y N 

6. Require transfer documentation to be 

completed in accordance with facility policy. 

The nurse manager educated RNs 

regarding ensuring that they are the 

individuals signing inpatient transfers 

and not licensed practical nurses. 

Monthly record audits are performed to 

ensure compliance. 

Y N 

7. Require discharge documentation to 

accurately reflect active outpatient 

medications. 

Staff physicians were educated on 

facility policy to ensure patients’ active 

medication lists are accurately 

reflected on discharge summaries. 

Monthly record audits are performed to 

ensure compliance. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Pharmacy Operations 

8. Require monthly inspections to be 

completed in all areas where CS are stored. 

The CS Coordinator educated 

inspectors regarding the requirement 

for monthly inspections. In the event 

an inspector cannot complete the 

inspection, the CS Coordinator is 

contacted, and an alternate is 

assigned. CS inspection data shows 

one missed CS inspection in FY 2010 

and FY 2011. 

Y N 

Medication Management 

9. Require staff to follow facility policy 

regarding medication disposition upon 

admission. 

A process for weekly random 

inspections to ensure medications are 

not stored on the unit has been 

implemented. The data reveals 

sustained improvement. 

Y N 

10. Require the Self-Medication Management 

Program to be implemented and managed in 

accordance with facility policy. 

The MH Service Line developed a 

handout to explain security 

requirements to patients and a 

template to document the required 

medication education. Practitioners 

write orders for the level of medication 

administration needed by a veteran on 

admission and as needed throughout 

treatment. Compliance is monitored, 

and data demonstrates sustained 

improvement. 

Y N 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

11. Require staff to document as needed 

medication effectiveness within the timeframe 

defined by facility policy. 

A process for a daily audit of 

compliance documentation has been 

developed. Nurse managers provide 

timely feedback and assist individual 

staff with compliance. 

Y N 

Emergency/Urgent Care Operations 

12. Require that patients discharged from the 

emergency department receive written 

discharge instructions. 

The Emergency Department Discharge 

Patient Education Template was 

developed and implemented. 

Documentation shows compliance with 

VHA guidelines. 

Y N 

13. Require that clinicians document 

inter-facility transfers in accordance with VHA 

policy. 

Implementation and continued use of 

the VA Inter-facility transfer form and 

I-Med Consent form ensure the safe 

and appropriate transfer of emergency 

department patients. This is in 

accordance with VHA policy. 

Emergency department monitors were 

completed in March 2010, and data 

demonstrated 100 percent compliance. 

Y N 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

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 60.0 63.7 56.5 59.6 59.2 56.5 

VISN 67.7 59.2 57.2 67.2 61.2 58.1 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

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

scores for 2009, 2010, and 2011. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2009 2010 2011 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

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

conditions9 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 13.34 9.00 11.31 * 16.79 12.44 

VHA 12.54 9.24 12.02 12.99 19.66 15.15 

* Not enough cases. 

9 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 16 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: November 2, 2011
 

From: Director, VA Midwest Health Care Network (10N23)
 

Subject: CAP Review of the VA Central Iowa Health Care System,
 

Des Moines, IA 

To: Director, Chicago Office of Healthcare Inspections (54CH) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I concur with the planned actions to be taken by VA Central Iowa Health 

Care System, Des Moines, IA, regarding the fifteen identified 

recommendations. 

JANET P. MURPHY, MBA
 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: November 1, 2011
 

From: Director, VA Central Iowa Health Care System (636A6/00)
 

Subject: CAP Review of the VA Central Iowa Health Care System,
 

Des Moines, IA 

To: Janet P. Murphy, Director, VA Midwest Health Care Network 

(10N23) 

See pages 19 through 23, below. 

DONALD C. COOPER
 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Comments to Office of Inspector General’s Report
 

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

in the Office of Inspector General report: 

OIG Recommendations 

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

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

Concur. 

Target date for completion: Completed 10/1/2011. 

The PR Coordinator will review the PR database at least bi-weekly to ensure that 

written requests for extensions are initiated and subsequently approved by the facility 

Director within the 120 day timeframe. 

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

reviews of current medications are completed and documented in the required 

timeframe prior to procedures requiring moderate sedation. 

Concur. 

Target date for completion: 1/15/2012. 

The process will be strengthened to ensure that the patient’s current medication list will 

be documented in the electronic medical record within the required timeframe for 

procedures requiring moderate sedation. Service Line leaders will be responsible for 

developing a specific process to include development of appropriate note templates, 

and a plan for provider and nurse education. Compliance with the new process will be 

monitored monthly for the first three months and then quarterly to ensure sustained 

improvement. 

Recommendation 3. We recommended that medical record review processes be 

strengthened to ensure that results of all medical record quality reviews are reported at 

least quarterly to the Medical Records Committee. 

Concur. 

Target date for completion: 2/1/2012. 

The medical record quality reviews will be conducted and reported by each of the 

facility’s Service Lines and reported to the Medical Records Committee on a quarterly 

basis. The Medical Records Committee will request corrective action plans as needed 

and monitor them monthly until the issues are resolved. 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Recommendation 4. We recommended that processes be strengthened to ensure that 

employees maintain current CPR certification and that the action required by facility 

policy is taken when employees do not maintain certification. 

Concur. 

Target date for completion: 2/1/2012. 

CPR certification of designated staff will be monitored on a regular and ongoing basis 

by the facility’s Learning Service through an education tracking software program. If a 

staff member does not maintain current CPR certification, he/she will be removed from 

direct patient care responsibilities and may be subject to disciplinary action. A process 

to document and track removals from direct patient care will be established in 

collaboration with the Human Resources Service Line and the data on removals 

reported to facility leadership on a monthly basis. 

All 23 staff identified by the OIG during the August 2011 CAP survey with expired 

certification at the time of survey are now recertified in CPR. 

Recommendation 5. We recommended that competency criteria be service-specific 

and that data be collected and reviewed during the reprivileging process in accordance 

with facility policy. 

Concur. 

Target date for completion: 2/1/2012. 

The Service Lines are revising their ongoing professional practice evaluation criteria to 

be provider and service-specific. Monitoring of data collection will be completed by the 

Service Chiefs and will be reported quarterly to the Executive Committee of the Medical 

Staff. 

Recommendation 6. We recommended that processes be strengthened to ensure that 

clinical privileges granted are appropriate to the providers’ training and experience. 

Concur. 

Target date for completion: 2/1/2012. 

Service Chiefs are reviewing clinical privileges at the time of credentialing to ensure that 

each provider has the appropriate level of privileges and that the facility can support 

provision of the services identified. 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

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

competency validation documentation is complete and legible.
 

Concur.
 

Target date for completion: 3/1/2012.
 

The facility will conduct a facility-wide audit of all nursing competencies for
 

completeness and legibility. Thereafter, random audits will be conducted each month
 

by the office of the Associate Director for Patient Care Services during calendar
 

year 2012 and reported to facility leadership on a monthly basis. Leadership will initiate
 

corrective actions as needed based on the audit results.
 

Recommendation 8. We recommended that management complete the facility-wide
 

nursing competency audit and initiate corrective actions as needed based on the audit
 

results.
 

Concur.
 

Target date for completion: 3/1/2012.
 

Management will initiate corrective actions as needed based on a facility-wide audit of
 

all nursing competencies for completeness and legibility.
 

Recommendation 9. We recommended that the facility update and strengthen the
 

current workplace violence policy to include detailed guidance for managing violent
 

incidents involving patients, employees, and visitors.
 

Concur.
 

Target date for completion: 7/1/2012.
 

The workplace violence policy will be revised and strengthened to include detailed
 

guidance for managing violent incidents involving patients, employees, and visitors.
 

Recommendation 10. We recommended that processes be strengthened to ensure
 

that brief incident reports are completed for all assaults involving patients.
 

Concur.
 

Target date for completion: 7/1/2012.
 

The facility will assess and revise, as needed, the current process for ensuring
 

completion of incident reports related to assaults. Staff will then be educated on the
 

revised process prior to implementation.
 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Recommendation 11. We recommended that processes be strengthened to ensure 

that when a patient’s record is flagged for a behavioral problem, the treatment team 

discusses the assault incident with the patient and documents the discussion in the 

medical record. 

Concur. 

Target date for completion: 7/1/2012. 

The Mental Health Service Line and the Disruptive Behavior Committee will revise the 

process for discussing behavioral problems and assault incidents with the involved 

veteran, and documenting that discussion in the veteran’s medical record. 

Recommendation 12. We recommended that annual N95 respirator fit testing be 

completed for all designated employees and that compliance be monitored. 

Concur. 

Target date for completion: 1/1/2012. 

Those identified employees needing N95 respirator fit testing are being scheduled for fit 

testing. To date, 84 percent of the identified employees have completed 

fit-testing. Integrated Safety Program staff will monitor the fit-testing program on a 

weekly basis to ensure that 100 percent compliance is achieved and maintained. 

Recommendation 13. We recommended that processes be strengthened to ensure 

that Veterans Canteen Service retail storage rooms are secured at all times. 

Concur. 

Target date for completion: 10/31/2012. 

All Veteran Canteen Service staff has received education and instruction regarding the 

requirement for retail storage rooms to be locked at all times when not actively in use. 

Veteran Canteen Service storage areas are currently located in a temporary location. 

At the temporary location all storeroom doors will have automatic door closures and will 

be locked and closed when stock is not actively being moved in or out of the area. 

Target date for completion is December 1, 2011. For Veterans Canteen Service 

permanent retail store location, all storerooms doors will have automatic door closures 

and key pads at each door. 

Recommendation 14. We recommended that processes be strengthened to ensure 

that all components of written advance directive notification are provided to patients and 

that notification is documented in the medical record. 

Concur. 

Target date for completion: 2/1/2012. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

The required elements of the Advance Directive Notification will be embedded into the 

electronic Admission Nursing Assessment template as a forced-field that the nursing 

staff will be required to address with the veteran during completion and documentation 

of the mandatory Admission Nursing Assessment. 

The nursing staff will be trained on the modified process and template by 

January 15, 2012 prior to implementation. Monitoring of the template to ensure that 

Advance Directive Notification is completed 100 percent of the time will be done 

monthly by the Nursing Record Review Team for six months following the date of 

implementation. 

Recommendation 15. We recommended that processes be strengthened to ensure 

that patient advance directive screening is accurately documented in the medical 

record. 

Concur. 

Target date for completion: 3/1/2012. 

The facility will revise the process for verification of the Advance Directive screening in 

the medical record. As part of the process, an audit team and schedule will be 

established to track and ensure compliance. Audit results will be shared with the Chief 

of Patient Care Services and the Social Work Executive for corrective actions as 

needed. 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

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	 Wachita Haywood, RN, Project Leader 

Lisa Barnes, MSW, Team Leader 

Verena Briley-Hudson, ARNP, MN 

Darlene Conde-Nadeau, NP 

Frank Keslof, MHA 

JoDean Marquez, RN 

Judy Montano, MS 

Roberta Thompson, LCSW 

Judy Brown, Program Support Assistant 

Gregory Billingsley, Office of Investigations 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the VA Central Iowa Health Care System, Des Moines, IA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Midwest Health Care Network (10N23) 

Director, VA Central Iowa Health Care System (636A6/00) 

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, Chuck Grassley, Tom Harkin, Claire McCaskill 

U.S. House of Representatives: Leonard Boswell, Bruce L. Braley, Sam Graves, 

Steve King, Tom Latham, David Loebsack 

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

VA OIG Office of Healthcare Inspections 25