Department of Veterans Affairs
	

Office of Inspector General
	

Healthcare Inspection
 

Oversight Review of
 

Dental Clinic Issues
 

Dayton VA Medical Center
 

Dayton, Ohio
 

Report No. 10-03330-148 April 25, 2011

VA Office of Inspector General
	

Washington, DC 20420
	
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)
 
i

Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Contents
	

Page
	

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

Introduction ..........................................................................................................1
 

Purpose........................................................................................................................... 1
 

Background .................................................................................................................... 2
 

A. SOARS ............................................................................................................. 2
 

1. Program................................................................................................... 2
 

2. Allegations Made to the SOARS Team.................................................. 2
 

3. SOARS Review Conclusions Related to the Dental Clinic.................... 2
 

B. Dayton Dental Clinic........................................................................................ 3
 

C. Disclosure of Adverse Events .................................................................................3
 

Scope and Methodology................................................................................................. 5
 

A. Onsite Visits and Interviews .............................................................................. 5
 

B. Document Reviews ............................................................................................ 5
 

Inspection Results and Conclusions ................................................................6
 

Issue 1: Dental Clinic Infection Control ....................................................................... 6
 

A. Policies, Procedures, and Training .................................................................... 6
 

B. Bloodborne Pathogens Infection Control .......................................................... 6
 

C. Conclusions Regarding Dental Clinic Infection Control................................... 9
 

Issue 2: VHA Responses to the Dental Service Allegations ........................................ 9
 

A. Medical Center, VISN, and VACO Responses ................................................. 9
 

B. Fact Finding Processes....................................................................................... 9
 

C. Dental Clinic Stand Down ............................................................................... 10
 

D. Local Improvements ........................................................................................ 10
 

E. Conclusions Regarding VHA Responses ........................................................ 11
 

Issue 3: Administrative Investigative Board............................................................... 11
 

A. Conclusions Regarding the AIB ...................................................................... 13
 

Issue 4: Clinical Review Board and Patient Notifications.......................................... 13
 

A. Initial CRB Deliberations ................................................................................ 14
 

VA Office of Inspector General 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

B. The CRB’s Final Recommendations ............................................................... 15
 

C. Conclusions Regarding the CRB ..................................................................... 17
 

Issue 5: Staffing and Workplace Environment ........................................................... 17
 

A. Staffing and VHA Response............................................................................ 17
 

B. Conclusions Regarding Staffing and VHA Response ..................................... 18
 

C. Work Environment........................................................................................... 18
 

Recommendations .............................................................................................18
 

Comments...........................................................................................................19
 

Appendixes
	

A. VISN Director Comments...................................................................................... 20
 

B. Medical Center Director Comments ...................................................................... 21
 

C. OIG Contact and Staff Acknowledgments............................................................. 23
 

D. Report Distribution................................................................................................. 24
 

VA Office of Inspector General 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Executive Summary
	

Introduction 

At the request of the Chairmen and Ranking Members of the Senate Committee on 

Veterans’ Affairs and the House Committee on Veterans’ Affairs, the Office of Inspector 

General Office of Healthcare Inspections reviewed infection control issues at the Dayton 

VA Medical Center, Dayton, OH (the medical center). 

On July 21, 2010, allegations of potential breaches in infection control practices were 

made to a VA System-Wide Ongoing Assessment and Review Strategy (SOARS) 

inspection team. The allegations pertained to improper infection control practices of a 

dentist at the medical center (the subject dentist). In consideration of these allegations 

the medical center temporarily suspended dental services and detailed several employees 

out of the dental clinic to other administrative duties. Reviews were initiated at the local 

VA Medical Center (VAMC), Veterans Integrated Service Network (VISN), and VA 

Central Office (VACO) levels. In addition, a VISN-level Administrative Investigative 

Board (AIB) was chartered. After a rapid response site visit by a VACO team, the 

Veterans Health Administration’s (VHA’s) Principal Deputy Under Secretary for Health, 

concerned about the possibility of bloodborne infection, convened a Clinical Review 

Board (CRB). This CRB was asked to: (1) conduct a clinical risk assessment, (2) identify 

the types of dental procedures at risk for disease transmission, and (3) make a 

recommendation as to whether a large-scale disclosure was indicated. 

Results and Conclusions 

We found evidence of lack of adherence to proper infection control policies and 

determined that the subject dentist did not comply with infection control and related 

procedures. We identified evidence that Dental Service management was aware of these 

infractions prior to the SOARS team visit. Subsequent to the SOARS visit, VHA’s 

response to the allegations was immediate and demonstrated appropriate concern for 

patient safety. The AIB established that the subject dentist repeatedly violated infection 

control standards over a multiyear period. The CRB properly executed its charges and 

directives, and its recommendations followed VHA’s notification for disclosure policy. 

Additionally, we confirmed that staffing levels in the dental clinic were suboptimal, and 

this may have increased the likelihood that deviations from approved infection control 

practices would occur. We also found that interpersonal relations among dental clinic 

staff were, at times, strained and negatively impacted the dental clinic. 

VA Office of Inspector General i 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Recommendations 

Recommendation 1: We recommended that the VISN Director review the findings 

related to the Dayton Dental Clinic, to include staffing issues, and take whatever action 

deemed appropriate. 

Recommendation 2: We recommended that the VISN Director ensure that the Dayton 

Medical Center Director requires the Dental Service to comply with the relevant infection 

control policies. 

Comments 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided an acceptable action plan (see Appendixes A and B, pages 20–22, for the 

Directors’ comments). We will follow up on the planned actions until they are 

completed. 

VA Office of Inspector General ii 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Introduction 

Purpose 

This review was performed at the request of the Chairmen and Ranking Members of the 

Senate Committee on Veterans’ Affairs and the House Committee on Veterans’ Affairs. 

During the week of July 20–23, 2010, a System-Wide Ongoing Assessment and Review 

Strategy (SOARS) team inspected the VA Medical Center, Dayton, OH (the medical 

center). On the morning of July 21, during the course of this inspection, two dental clinic 

employees approached a team member requesting to speak. A meeting did not occur 

immediately, but later in the morning, while in the dental clinic laboratory, these same 

two employees again encountered SOARS team members. The employees articulated 

allegations about aspects of a staff dentist’s practice. These allegations pertained to this 

dentist’s handling of dental burs1 and noncompliance with dental infection control 

guidelines. The improprieties allegedly had been ongoing, and were continuing to occur. 

The allegations, if true, would have represented significant breaches of both medical 

center and Veterans Health Administration (VHA) national standards regarding the 

handling of reusable medical equipment (RME), adherence to standards of infection 

control, and professional comportment expected of VHA dentists. At that time, it was 

also alleged that these concerns had been previously brought to Dental Service 

management’s attention. 

This encounter, and the allegations, set in motion no less than five VHA investigations 

(including an Administrative Investigative Board [AIB]) that produced reports 

culminating in the notification, on February 8, 2011, to 535 patients of the medical 

center, “that VA’s own internal reviewers discovered that a dental clinician was not 

always following standard infection control practices in the Dental Clinic [sic] at the 

Dayton VA Medical Center.” 

No specific case of patient injury was asserted; rather, the allegations pertained to overall 

improper practices. The purpose of this oversight review is to detail the relevant facts 

regarding this incident and to make recommendations to address the issues discussed in 

this report. 

1 A dental bur is a rotary cutting device, used in a handpiece, that is intended to cut hard structures in the mouth, 

such as teeth or bone as well as hard metals, plastics, porcelains, and similar materials used in the fabrication of 

dental devices. http://de.dict.md/definition/Bohrer ,accessed 2/12/2011. 

VA Office of Inspector General 1 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Background 

A. SOARS 

1. Program 

VHA operates a program of proactive VA medical center inspections known as SOARS 

visits. Its mission “is to provide assessment and educational consultation to volunteer 

facilities using a systematic method for on-going self-improvement.” SOARS inspection 

teams are composed of program staff and field (Veterans Integrated Service Network 

[VISN] and medical center level) health care experts. 

2. Allegations Made to the SOARS Team 

On July 21, 2010, two dental clinic employees approached a SOARS team member who 

later detailed the interaction in depth in a Report of Contact (ROC). This ROC indicates 

that two dental technicians voiced concerns of “violations of RME standards in the 

Dental Department.” The technicians noted that “the problem involved a particular 

doctor that worked in Dental [sic].” In response, the SOARS Team Leader documented 

that “...one of the employees relayed [concerns] about processes that were taking place 

in the Dental Clinic [sic] related to sterilization and cleaning of dental RME. They 

offered that a Dentist [sic] in the Dental [sic] clinic was inappropriately cleaning and 

storing dental burs as well as reusing them on various patients without appropriate 

cleaning procedures. When asked whether leadership was aware of this concern, the 

employee said that [he/she] had informed the Chief of Dental, and nothing was being 

done.” The complainants also indicated, “we have talked to everyone and no one cares, 

so we want to talk to you.” 

Further, the SOARS team cited being informed that a particular dentist “uses burs to 

make adjustments on dentures and will not sterilize the burs between patients...even if 

there is blood on the dentures [he/she] is working on.” The complainants alleged that 

they told [the subject dentist] that [he/she] needed to have the burs sterilized between 

patients and were told by [the subject dentist] “leave your hands off of my burs.” 

3. SOARS Review Conclusions Related to the Dental Clinic 

The final SOARS report stated, “During the Dental [sic] review, 3 employees notified the 

SOARS team of their alleged concerns with dental instruments not being properly 

cleaned between patients. They stated they had notified their supervisor without actions 

being taken. The SOARS Team notified the Medical Center Director and recommended 

further fact finding be completed immediately.”2 

2 While in the dental lab, a third dental employee also made allegations. 

VA Office of Inspector General 2 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

In its final report, one of the SOARS team’s “priority areas for improvement” was for the 

medical center to: “Complete a comprehensive assessment on the RME concerns 

involving the Dental [sic] clinic.” 

B. Dayton Dental Clinic 

The dental clinic performs a full spectrum of dental and oral surgical procedures. The 

American Dental Association (ADA) recognized dental specialties practiced at the 

medical center include general dentistry, oral and maxillofacial surgery, oral and 

maxillofacial radiology, periodontics,3 and prosthodontics.4 In July 2010, at the time of 

the SOARS inspection, the dental clinic had seven dentists and an oral surgeon, two 

dental hygienists, seven dental assistants (two expanded function, five non-expanded 

function),5 and three dental laboratory technicians.6 In FY 2009, the dental clinic treated 

3,164 unique patients, and in FY 2010 the clinic treated 3,005 unique patients. 

The dentists, oral surgeon, administrative officer, expanded function dental assistants, 

registered dental hygienists, and dental laboratory technicians report to the service chief, 

while the non-expanded function dental assistants and administrative program staff report 

to the Dental Service’s administrative officer. The Chief of Dental Service reports to the 

medical center Chief of Staff (COS). 

The dental clinic has a General Practice Residency, which is an independent medical 

center residency (as opposed to being the recipient of university residents rotating 

through the dental clinic). It presently has three residents, although it is authorized for 

four. The last accreditation review occurred on September 20, 2006, and the Commission 

on Dental Accreditation adopted a resolution to grant the program the accreditation status 

of “approval without reporting requirements” at its January 25, 2007 meeting. The next 

scheduled accreditation site inspection is scheduled for September 2013. 

C. Disclosure of Adverse Events 

VHA Directive 2008-002 provides guidance for disclosure of adverse events related to 

clinical care to patients or to their personal representatives. 

3 Periodontics is the diagnosis and treatment of gum disease. 

4 Dental prosthetics or prosthetic dentistry is the area of dentistry that focuses on the replacement of teeth and related 

mouth and jaw structures with artificial devices, including dentures and implants.

5 Expanded function dental assistants have advanced patient care skills beyond the level provided by non-expanded 

function assistants and are at a higher pay scale level.

6 Dental clinic staffing has evolved somewhat since July 2010. As of January 2011, the organizational chart reflects 

staffing as follows: 26.4 FTE: Chief, Dental Service, 1.0 FTE; Assistant Chief of Dental Service, 1.0 FTE; dentists 

(general), 4.0 FTE; oral surgeon, 1.0 FTE; periodontist, 0.2 FTE; endodontist, 0.2 FTE; expanded function dental 

assistants, 2.0 FTE; dental assistant (oral surgery), 1.0 FTE; dental assistant (lead), 1.0 FTE; dental assistants, 

8.0 FTE; dental hygienists, 2.0 FTE; dental laboratory technicians, 2.0 FTE, administrative officer, 1.0 FTE; and 

program support assistants, 2.0 FTE. 

VA Office of Inspector General 3 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Adverse events are defined as “untoward incidents, therapeutic misadventures, iatrogenic 

[physician-caused] injuries, or other adverse occurrences directly associated with care or 

services provided within the jurisdiction of a medical center, outpatient clinic, or other 

VHA facility.” 

VHA Directive 2008-002 defines large-scale disclosure of adverse events as “involving a 

large number of patients, even if at a single facility.”7 Authority and responsibility for 

large-scale disclosures resides with VHA’s Principal Deputy Under Secretary for Health 

(PDUSH). Often the issues will be clear and the PDUSH will proceed according to the 

facts and available medical science. However, if the issues are unclear, the PDUSH can 

request that the Deputy Under Secretary for Health for Operations and Management 

(DUSHOM) convene the Clinical Risk Board (CRB),8 an ad-hoc consultative board. 

Key issues that the CRB is expected to address include the number of veterans exposed 

or potentially exposed; the probability that the adverse event will cause harm; the nature, 

magnitude, and duration of the potential harm; and the availability of treatment to prevent 

or ameliorate harm. To estimate the number of veterans potentially exposed, the CRB 

must consider the risk period when conditions were non-compliant or deficient. The risk 

period dates are referred to as “lookback” dates in the remainder of this report. 

VHA Directive 2008-002 recognizes that although it is difficult to weigh all benefits and 

harms, situations prompting a decision whether to conduct large-scale disclosure of 

adverse events likely involve the following considerations: 

a.	 Are there medical, social, psychological, or economic benefits or burdens to the 

veterans, resulting from the disclosure itself? 

b. What is the burden of disclosure to the institution, focusing principally on the 

institution’s capacity to provide health care to other veterans? 

c.	 What is the potential harm to the institution of both disclosure and non-disclosure 

in the level of trust that veterans and Congress would have in VHA? 

The CRB may choose to recommend notification if “one patient or more in 

10,000 patients subject to the event or exposure is expected to have a short-term or 

long-term health effect that would require treatment or cause serious illness if 

untreated.”9 

7 Attachment A of VHA Directive 2008-002 recognizes that adverse events with a known risk of serious future
 

health consequences may be associated with an “extremely small” risk.

8 The CRB was formerly known as the Clinical Risk Assessment Advisory Board (CRAAB).
 9 This material is quoted from Department of Veterans Affairs Office of Inspector General, Healthcare
 

Inspection – Use and Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities, Report
 

No. 09-01784-146, June 16, 2009.
 

VA Office of Inspector General 4 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Scope and Methodology 

A. Onsite Visits and Interviews 

We visited the medical center from December 14–16, 2010. We interviewed relevant 

clinical and administrative staff, including the Medical Center Director, Acting COS, 

Quality Manager, infection control practitioner, and the senior infectious diseases 

physician. We interviewed past and current staff of the dental clinic. However, we were 

unable to interview the original SOARS complainants due to their departure from the 

medical center, as well as one dentist and the former COS, due to retirement. We 

interviewed senior VISN 10 staff, including the Network Director, Chief Medical Officer, 

Quality Management Officer, and the Network Patient Safety Officer. 

We interviewed senior VA Central Office (VACO) officials including the Under 

Secretary for Health; PDUSH; Acting Assistant Deputy Under Secretary for Health, 

Clinical Operations and Management; Associate Deputy Under Secretary for Health for 

Quality and Safety; National Program Director for Medicine; Assistant Under Secretary 

for Health for Dentistry; and Infection Control Consultant for VHA’s Office of Dentistry. 

We interviewed members of the AIB, including its attorney-advisor. One AIB member 

was unavailable due to health reasons. 

We interviewed medical consultants from the Prevention and Response Branch of the 

Centers for Disease Control and Prevention (CDC) and VA Office of Public Health and 

Environmental Hazards (OPHEH) staff. We also interviewed attorneys from VA’s 

Office of General Counsel (OGC). 

B. Document Reviews 

We reviewed the AIB and its testimony. We reviewed VISN Issue Briefs; CRB charters, 

memoranda, and reports; relevant medical and dental literature; facility-level Standard 

Operating Procedures (SOPs) and policies; relevant committee minutes; credentialing and 

privileging documents; dental clinic infection control training records; and email 

communications. We also reviewed VHA directives, CDC guidelines, Occupational 

Safety and Health Administration’s (OSHA) Bloodborne Pathogens Rule, and ADA 

guidelines. 

During the course of our inspection, we were informed that the skills of another dentist 

(not the subject dentist) had been brought into question. The medical center undertook a 

review of the dental care provided by this individual through normal quality assurance 

procedures. This issue is not addressed further in this report. 

This inspection was performed in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of Inspectors General on Integrity and Efficiency. 

VA Office of Inspector General 5 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Inspection Results and Conclusions
	

Issue 1: Dental Clinic Infection Control 

A. Policies, Procedures, and Training 

Dental infection control practices are governed by a multitude of regulations, standards, 

and recommendations related to the appropriate use of personal protective equipment 

(PPE), hand hygiene, reprocessing of RME, and other measures to safeguard the health of 

patients and staff. VHA, CDC, The Joint Commission (The JC), and OSHA have 

published documents to facilitate compliance with recommendations and requirements. 

The medical center has also developed local policies related to hand hygiene, RME, 

bloodborne pathogens, and disinfectants. The medical center requires its employees to 

comply with these established infection control policies. 

RME is defined as any medical equipment designed by the manufacturer to be reused for 

multiple patients. Dental RME includes dental handpieces, which are the high-speed 

dental drills used to remove tooth material prior to filling, and dental instruments such as 

stainless steel dental mirrors, probes, burs, and retractors. These are classified as critical 

items10 and must be disinfected and sterilized between patients. Applicable policies 

include VHA Directive 2009-004, VHA Directive 2009-031, and VHA’s SPD 

Handbook 7176. As well as policies governing infection control practices, there are also 

policies governing disinfectant agents and their use. 

In our review of the dental clinic staff training records provided to us by the medical 

center for March 2007–October 2010, we found that infection control training was not 

completed by many employees on an annual basis as required. 

B. Bloodborne Pathogens Infection Control 

Infections may be transmitted through dental procedures by several routes, including 

transmission of infection from patient to dental health care worker (DHCW), from 

DHCW to patient, and from patient to patient. VHA and the medical center have policies 

in place designed to assure that employees and patients are protected against infection by 

bloodborne pathogens (HIV, hepatitis B, hepatitis C).11 

The Medical Center Director ensures the implementation and enforcement of the Dental 

Service Bloodborne Pathogens Exposure Control Plan. Compliance with the exposure 

control plan is the responsibility of the Chief of Dental Service. All employees are 

10 Critical Items: Objects that enter sterile tissue or the vascular system – for example: orthopedic prosthetic devices,
 

surgical instruments, and ultrasound probes used in sterile body cavities.

11 Department of Veterans Affairs Dayton VA Medical Center Dental Service, Bloodborne Pathogens Exposure
 

Control Plan, November 10, 2008
 

VA Office of Inspector General 6 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

responsible for complying with the procedures contained in the plan. This plan includes 

the following procedures: 

	 PPE is never worn outside the work area. 

	 Computer keyboards, telephones, intercoms, and similar equipment will never be 

handled with contaminated gloves unless there is a barrier present. 

	 Eating, drinking, applying cosmetics, or handling contact lenses is not permitted in 

the dental operatories, laboratory, or any direct patient care area. 

	 All impressions will be decontaminated upon removal from the mouth. 

	 When performing procedures involving touching blood and/or saliva the following 

are mandatory items of PPE: gloves, masks, face shields/glasses, and impervious 

gowns. Heavy duty gloves are required for instrument preparation and 

disinfection. 

If an exposure incident occurs, the policy states that the employee will immediately 

report the exposure incident to the employer through their immediate supervisor with 

additional steps to be taken to protect the health of the employee. 

The Infection Control Policy dated November 13, 2008, states that the Chief of Dental 

Service has the authority and responsibility for the operation of the Infection Control 

Program. Dental clinic employees are responsible for complying with the procedures 

contained within the policy. 

This policy states that “Standard (Universal) precautions will be observed in the Dental 

Service in order to prevent contact with blood or other potentially infectious materials.” 

The policy defines standard precautions as “a method of infection control in which all 

human blood and certain human body fluids (saliva in dentistry) are treated as if known 

to be infectious for HIV, HBV [hepatitis B virus], and other bloodborne pathogens. 

Standard Precautions means that the same infection control practices are used for all 

patients.” This policy includes the following procedures: 

	 All dental instruments, equipment, and devices that enter the patient’s vascular 

system or penetrate the skin, oral mucosa, or teeth must be sterilized prior to use 

on a patient or discarded as a single use item. 

	 All dental instruments, equipment, and devices that contact mucous membranes 

but do not penetrate the patient’s skin or mucosa will be sterilized when possible 

or disinfected with an Environmental Protection Agency (EPA) approved 

disinfectant. 

	 Single-use, sterile burs and diamonds will be utilized whenever possible. All other 

burs (including lab burs) will be sterilized initially and between uses. 

VA Office of Inspector General 7 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

	 Dental prostheses, impressions, and other prosthodontic materials will be 

thoroughly cleaned, disinfected with an EPA-registered hospital disinfectant with 

a tuberculocidal claim, and thoroughly rinsed prior to being taken to the dental 

laboratory. Wex-CideE-128® is the product currently being utilized for this 

purpose. Prostheses/impressions/other prosthodontic materials should be 

immersed for at least 10 minutes.12 

	 Under no circumstances will contaminated appliances or equipment be taken into 

the dental laboratory for grinding or polishing. 

	 Contaminated gloves will not be worn into the dental lab. 

VHA’s Required Hand Hygiene Practices states that all VHA facility directors are 

responsible for ensuring that all health care workers in direct patient care areas put gloves 

on when contact with blood or other potentially infectious materials, mucous membranes, 

and non-intact skin could occur. Employees must remove gloves after caring for the 

patient and not wear the same pair of gloves for the care of more than one patient. 

The subject dentist did not comply with infection control and related policies. A clinic 

dentist informed the Chief of Dental Service in a June 29, 2010, email that: 

You have [a dentist] who repeatedly violates basic infection control protocols.
 

This includes:
 

a.	 Not cleaning a room after seeing patients and then boasting that [he/she] 

“works without an assistant”. [sic] 

b.	 [allegation not directly observed by the writer] 

c.	 Using bare hands in the patients [sic] mouth 

d.	 Answering [his/her] cell phone with gloves on [his/her] hands, then 

putting those gloves back in the patients [sic] mouth without changing 

the gloves and/or cleaning the phone 

In a memorandum for the record dated August 16, 2010, the Chief of Dental Service 

indicated that “[a dentist] would perform non-patient activities (talking on the phone, 

cell-phone, drinking coffee), or be walking in the hallway with [his/her] purple patientcare gloves on. I have indeed witnessed this activity on several occasions.” 

Multiple dental clinic employees told us they had personally observed various infection 

control policy violations by the subject dentist. Their observations included failing to 

disinfect, or incorrectly disinfect, denture prostheses prior to transferring them to the 

dental laboratory and wearing gloves outside the operatory. They told us that the subject 

dentist went directly from one patient to another without changing exam gloves and did 

12 The current policy now specifies Dispatch®, which requires immersion for 1 minute. 

VA Office of Inspector General 8 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

not properly clean and disinfect the operatory. Individuals told us that unsterilized 

instruments were reused on more than one patient. 

C. Conclusions Regarding Dental Clinic Infection Control 

The subject dentist did not adhere to established infection control guidelines and policies, 

and multiple dental clinic staff had direct knowledge of these repeated infractions. These 

violations of infection control policies placed patients at risk of acquiring infections 

including those that are bloodborne. 

Issue 2: VHA Responses to the Dental Service Allegations 

Immediately after the allegations concerning the Dental Service were made to the 

SOARS team, VHA launched a series of reviews and investigations at the local VAMC, 

VISN, and VACO levels. These included a compliance review; review of Supply, 

Processing and Distribution (SPD) practices; onsite review by a VACO fact finding team; 

and convocation of an AIB. These reviews quickly resulted in temporary closure of the 

dental clinic, detailing of several employees out of the clinic to other administrative 

duties, institution of local improvements, and, at a national level, empanelling a CRB. 

The latter would be called upon to assess possible notification to patients of infection 

control breaches. Key activities and outcomes are summarized below. 

A. Medical Center, VISN, and VACO Responses 

The SOARS Team reported the July 21, 2010, allegations to the Medical Center Director 

the day they were received, and the director notified the VISN within 24 to 48 hours. 

The VISN 10 Director immediately notified VACO senior management. Within a matter 

of days, VISN leadership began the process of assessing the extent and validity of the 

allegations. 

B. Fact Finding Processes 

A series of fact finding investigations and investigative bodies were activated in parallel 

and had specific issues to address. 

At the local level, the Medical Center Director requested a fact finding review by the 

compliance and business integrity officer. They placed the subject dentist on 

administrative detail on July 29, 2010. The VISN 10 Director convened an AIB after 

consultation with VACO. Furthermore, an SPD team conducted a planned assessment of 

SPD procedures August 10–13, 2010. 

Parallel to the AIB actions, VACO assembled a rapid response fact finding team for an 

onsite visit August 17–18. The goal of this visit was to rapidly assess the potential risk of 

patient exposure to bloodborne pathogens and disclosure options and to determine the 

VA Office of Inspector General 9 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

need for a CRB. Also, the VACO team wanted to ascertain the availability of the 

medical records that would be needed to effectuate a large-scale notification. On 

August 19, the team produced an Executive Summary Report and briefed the PDUSH 

and other VACO senior leadership. It concluded from its interviews with key dental 

clinic personnel that the subject dentist had placed patients at risk of potential exposure to 

bloodborne pathogens through the practice of re-using dental instruments without proper 

reprocessing. Its two key recommendations were (1) to immediately close the dental 

clinic, which was implemented the following day and (2) to proceed with a CRB to fully 

examine the potential risks to patients and the options for disclosure. 

C. Dental Clinic Stand Down 

From August 19, 2010, through September 9, 2010, the dental clinic temporarily 

suspended operations. The VISN and medical center supervised an extensive reorganization of the dental clinic. This included employee training, employee counseling, 

environment of care improvements, and updates in operating procedures. Dayton’s 

Quality Manager notified The JC and the Commission on Accreditation of Rehabilitation 

Facilities that “On August 19, 2010, Dental [sic] services at the Dayton VAMC were 

temporarily suspended as a precautionary measure to evaluate infection control 

practices.” 

In mid-August, several personnel actions were initiated. The Chief of Dental Service and 

the Dental Administrative Officer were placed on administrative detail. Additionally, 

another dentist was relieved of direct patient care responsibilities pending review of 

patient care allegations. An Acting Chief of Dental Service was appointed and relocated 

onsite from another VISN facility. 

On September 8, a VHA national SPD official arrived onsite to review the changes 

implemented in the SPD practices and SOPs. The next day, VHA’s national dental 

infection control consultant made a site visit to assess the policies and to review 

procedures and revisions made pursuant to resumption of dental clinic operations. On 

September 10, the dental clinic re-opened and resumed operations, guided by “internal 

and external review of infection control practices, employee competencies, environment 

of care evaluations, and RME reprocessing.” 

D. Local Improvements 

During the dental clinic closure, the local infection control practitioners and the Infection 

Control Consultant to the VACO Office of Dentistry conducted special education 

sessions on infection control. Dental employees reorganized the clinic’s equipment and 

supplies, and physical repairs were completed. 

A number of other infection control and safety issues were addressed and remediated as a 

result of VHA’s investigations. The dental clinic was renovated to separate designated 

VA Office of Inspector General 10 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

areas for soiled and clean utility spaces. Other improvements included revised infection 

control practices related to operatory instrument sets and inventories, updated SOPs for 

RME, established a staff lounge, and installed negative pressure monitoring devices in 

the dental laboratory. The Infection Control Program also made significant 

improvements. These included establishing a dashboard and inspection checklist to track 

observations and infection control compliance, appointing a dentist as a member of the 

Infection Control Committee, conducting routine observations of dental staff to ensure 

proficiencies in handling RME, and placing bloodborne pathogens training into the 

Learning Management System for better tracking of compliance. All dental staff 

employees were retrained on infection control practices and the care of RME. 

E. Conclusions Regarding VHA Responses 

The response to the allegations was immediate and decisive and demonstrated a clear 

concern for patient safety. Key dental clinic staff were immediately placed on 

administrative detail. The subsequent decision to temporarily close the clinic allowed the 

medical center to conduct assessments and implement necessary changes. An Acting 

Chief of Dental Service and Acting Administrative Officer were rapidly identified and 

assigned. They coordinated the necessary staff training and the environmental 

improvements and created the process of rebuilding teamwork, trust, and a culture of 

safety. 

Issue 3: Administrative Investigative Board 

VA Handbook 0700 details specific procedures to implement the objectives and 

requirements of an AIB. The Handbook establishes operational requirements and 

procedures for convening, conducting, reporting, and reviewing administrative 

investigations. AIBs should attempt to review all available documents, records, and other 

information that are material to the issues of investigation, or that may reasonably lead to 

discovery or development of material evidence, except as specifically prohibited. On 

July 29, 2010, the VISN 10 Director charged the medical center to convene an AIB. The 

AIB was composed of five members: the Chair (an Associate COS/podiatrist), a dentist, 

an infection control nurse, an SPD technical advisor, and a human resources/labor 

relations technical advisor (regional counsel). 

The AIB’s expressed purpose was to investigate the facts and circumstances regarding 

allegations outlined in the July 2010 SOARS ROC documents received by the VISN 10 

Director from the medical center Director. Initially, the AIB was tasked to determine: 

	 Whether there was a deviation in any dental standard of practice and/or improper 

handling, cleaning and/or disinfection of dental burs during fitting procedures by 

the dentist as alleged in the ROC and occurring in the dental clinic and/or dental 

laboratory at the medical center. 

VA Office of Inspector General 11 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

	 Whether there was evidence to support that the dental technicians referenced in the 

ROC (or others) communicated their concerns to their supervisor or other 

management official(s) as indicated/implied in the ROC. If so, identify who knew 

what, and when, or if action was taken. 

On August 16, 2010, the AIB was given an extension on its expected completion date. 

The scope of the AIB was expanded to allow for additional testimony as requested by the 

CRB on September 8 and to allow for the interview of a former Chief of Dental Service. 

The AIB concluded its testimony on September 14. Its findings and conclusions were 

accepted by the VISN 10 Network Director on October 5. The document was forwarded 

to the medical center Director on October 25 and was received on October 27 for 

appropriate action. On that same day, the medical center Director authorized a new, 

separate AIB to examine the work environment within the dental clinic. The second AIB 

was instructed to complete its work by December 18. 

During the course of the AIB authorized on July 29, a total of 31 witnesses were 

interviewed. They offered testimony sworn under oath and in the presence of a court 

reporter. Select witnesses were called back two or even three times in an effort to allow 

AIB members to ask follow-up or additional questions and to provide an opportunity to 

obtain fully comprehensive testimony. All witnesses were afforded the option of having 

personal counsel accompany them to their depositions. 

Individuals deposed during the entirety of the AIB process included the subject dentist; 

the current COS, the Chief of Dental Service (on administrative detail), the Acting Chief 

of Dental Service, the former Chief of Dental Service, the Administrative Officer of 

Dental Service, three current staff dentists, a retired staff dentist, two dental residents, 

three former dental residents, seven current dental assistants, a former dental assistant, 

three dental laboratory technicians, two registered dental hygienists, the Safe Patient 

Handling Coordinator, and two SOARS team members. 

After considering the totality of the record and the discovery process testimony, the AIB 

concluded that the subject dentist did, in fact, repeatedly violate infection control 

standards over a multiyear period. The AIB also concluded that testimony supported the 

subject dentist’s violations as beginning in 1992, and without curtailment of this dentist’s 

privileges by knowing superiors, there was potential exposure of patients to bloodborne 

pathogens. 

Additional AIB conclusions pursuant to the subject dentist included awareness by a 

former Chief of Dental Service and the current Chief of Dental Service of violations of 

VA regulations on the limited use of government equipment (work computers) during the 

subject dentist’s tour of duty. 

VA Office of Inspector General 12 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

A. Conclusions Regarding the AIB 

The AIB was thorough in its fact finding process, deposing 31 witnesses, some witnesses 

being called back for a second or even third appearance before the AIB. Witnesses 

included current and former leadership in the Dental Service as well as current and 

former staff, support staff, and trainees. 

Witness testimony may be gathered by various methods, including such instruments as 

written affidavits, verbatim transcripts, or recordings of live testimony. The AIB 

members spent a significant amount of time travelling onsite, preparing for the 

examination of witnesses, conducting in-person depositions, and reviewing/weighing the 

testimony generated. All witnesses were sworn under oath, and testimony was recorded 

in its entirety by a court reporter in attendance. Conducting the AIB was a 

time-consuming assignment and was carried out seriously and conscientiously by the 

AIB. 

VA Handbook 0700 (Ch. 5, sec. b-1) states that witnesses do not have the “due process” 

rights that apply to, for example, adverse personnel actions. While the AIB did 

successfully generate a very thorough document, there were select instances of appearing 

to lead a witness or of warning a sworn witness of their duty “to tell the truth.” While 

these instances occurred relatively sparingly and do not undermine the substantive merit 

of the AIB’s conclusions, they were, nonetheless, unnecessary and otherwise detracted 

from the procedural tenor of the hearings. 

In conducting the AIB, investigators sometimes discover significant information 

concerning matters that may merit some action or further inquiry but may be outside the 

scope of the assigned original investigation, as happened here. In such a circumstance, 

VA Handbook 0700 specifies that the AIB should provide such information promptly to 

the Convening Authority. Appropriately, this was done in the present case, and the scope 

of the investigation was expanded by the Convening Authority as documented. 

VACO, upon receiving the AIB conclusions, conferred with the OGC, seeking their 

advisory role regarding disclosure deliberations. The OGC met with VHA on 

November 3, 2010, and was specifically asked to review the transcripts from the AIB, 

receiving access to them on November 5. The review was completed and submitted to 

VHA on November 16, and the OGC again met with VHA on November 17 to review 

their findings. 

Issue 4: Clinical Review Board and Patient Notifications 

The need to convene a CRB was anticipated early on during VHA’s initial investigations 

into the allegations. Once it was clear that infection control violations had likely 

occurred, it was necessary to identify and outline the extent of the exposures, identify 

which patient populations were placed at risk, and analyze if and how those patients 

VA Office of Inspector General 13 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

should be informed of their potential exposure. An analysis of this scope would be 

complex and require an in-depth assessment of infectious disease transmission risk, 

patient safety, and ethical concerns. The initial CRB charge letter was sent 

September 1, 2010. Subsequently, the CRB convened four times over 4 months, refining 

and clarifying its assessment and disclosure recommendations throughout the process. 

A. Initial CRB Deliberations 

On August 30, 2010, VACO senior leadership held a meeting with subject matter experts 

in which the decision was made to convene the full CRB. The initial scope of the CRB 

as outlined in the charge letter was to: (1) conduct a clinical risk assessment, (2) identify 

the types of dental procedures at risk for disease transmission, and (3) make a 

recommendation as to whether a large-scale disclosure was indicated. If the CRB 

recommended a large-scale disclosure, it was to identify which patients should be 

notified, determine whether the disclosure should include deceased veterans’ next of kin, 

and define the lookback timeframe. The CRB was also tasked to provide justification for 

its recommendations. 

The CRB met on September 2, and issued its first report to the PDUSH on September 3. 

It conducted its review with members of the medical center, the VISN 10 leadership 

team, members of the site visit team, the VHA dental program office, and the VHA 

National Director for Infectious Diseases. Multiple documents for fact finding included 

the charge letter, the issue brief and update, AIB testimony of one dental clinic staff 

member, the AIB summary, the VACO August fact finding team report, a dental office 

review by the Office of Dentistry Consultant for Infection Control, OPHEH reviews, 

VACO’s summary of the site visit to the medical center, a timeline of events, and 

universal precautions history and synopsis. 

The CRB report identified three practices by the subject dentist that posed a potential risk 

for infection transmission. First, the subject dentist did not properly disinfect dentures 

when taking them to and from the dental laboratory. This practice breach potentially 

contaminated laboratory equipment and surfaces. Second, the subject dentist wore soiled 

gloves and gowns outside the dental operatory and the dental clinic and did not change 

gloves between patients, potentially contaminating common use areas. Third, the subject 

dentist used the same dental equipment (such as burs, handpieces, and hand instruments) 

on patients without cleaning or sterilizing the equipment between patients. These 

violations increased the risk of patient-to-patient disease transmission. 

In forming its recommendations, the CRB considered only the risk of transmission of 

bloodborne viral infections (HIV, hepatitis B, and hepatitis C). To assess the risk to 

patients posed by these practices, the CRB also considered reviews of the medical and 

dental literature on the transmission of bloodborne viral infections in dental clinics. It 

was able to risk stratify the patients based on the invasiveness of the procedure a patient 

received in the clinic, including removable and fixed (crowns and bridges) 

VA Office of Inspector General 14 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

prosthodontics, restorative fillings, and invasive procedures such as extractions and 

periodontal scaling. 

The initial September 3, 2010, CRB report recommended disclosure to all patients who 

had received invasive dental procedures and restorative care from the subject dentist 

since 1975. It recommended that testing for the bloodborne pathogens (HIV, hepatitis B, 

and hepatitis C) should be offered to these patients. The CRB also recommended that the 

AIB obtain further testimony from the dental staff to determine whether the subject 

dentist was reusing needles and/or drug vials and to clarify the subject dentist’s infection 

control practices prior to 1990. The CRB advised that, with evidence that the subject 

dentist did not reuse needles or vials and practiced with a dental assistant who monitored 

the dentist’s infection control practices prior to 1990, it could narrow its disclosure 

recommendations to include fewer patients and shorten the lookback timeframe. 

Based on the September CRB report recommendations, the scope of the AIB was 

expanded. The AIB team revisited the medical center and obtained further testimony. 

However, senior VACO leadership reviewed the AIB testimony and had reservations 

regarding the credibility of key testimony relative to infection control breaches. 

Subsequently, it requested that the OGC review the testimony in order to identify which 

witnesses had direct first hand observation of breaches and the nature of these breaches. 

After multiple senior level discussions, the DUSHOM re-convened the CRB to further 

clarify the risk assessment and disclosure issues. In his November 19 letter to the Chair 

of the CRB, the DUSHOM revised its scope. The CRB was to review the additional 

testimony indicating that the subject dentist did not reuse needles or vials and that he/she 

had a dental assistant prior to 1992. The CRB was also directed to review the AIB’s 

supplemental testimony and reports. Using this additional information, it was to again 

outline a recommendation on disclosure, identify the specific patient population and 

dental procedures, and define the lookback timeframe. 

The CRB met again on November 23 and December 2 to consider the new information 

provided by the subsequent AIB testimony, the analysis of the testimony by the OGC, 

and additional VACO and VISN 10 summary reports and findings. The meetings were 

conducted with members of the VISN 10 leadership team, members of the site visit team, 

the VHA dental program office, the AIB Chair, the VHA National Director for Infectious 

Diseases, and the Director of Public Health Surveillance and Research, and the Senior 

Medical Advisor of OPHEH. In all, 45 additional documents were reviewed. 

B. The CRB’s Final Recommendations 

A key factor in determining the CRB’s final recommendations was its conclusions 

regarding the extent and duration of the subject dentist’s infection control infractions. In 

its review of the testimony, the CRB felt there was sufficient evidence to support a 

conclusion that major infection control breaches did not likely occur prior to 1992, when 

VA Office of Inspector General 15 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

the subject dentist was practicing with a dental assistant. It was also able to limit the size 

of the patient population placed at risk to those undergoing only more invasive 

procedures which might provide a portal of entry into the bloodstream. Such exposure 

could thus result in disease transmission from one patient to another. 

The CRB submitted its revised set of recommendations to the PDUSH on 

December 3, 2010. By a six to one vote, it recommended that the original disclosure 

recommendations be narrowed to include only more invasive dental procedures and that 

the lookback be limited to patients treated from January 1, 1992, onward. It identified 

specific invasive dental procedures to include: extractions and periodontal scaling, some 

restorative fillings, and fixed prosthodontics (crowns and bridges). The dissenting voter 

felt there was insufficient clinical or scientific proof that hepatitis C or HIV have been 

transmitted in dental settings. The dissenter also noted that “the risk of 

patient-to-patient transmission of bloodborne pathogens from occult blood in saliva 

cannot be determined and is biologically plausible.” 

The CRB further recommended that the disclosure “should emphasize that the risk of a 

bloodborne infection to patients is low.” It also recommended that each patient be 

offered serologic testing for hepatitis B, hepatitis C, and HIV. This testing would be part 

of an investigation for the purpose of identifying whether exposure in a dental clinic is 

associated with transmission of bloodborne pathogens, as there is little scientific evidence 

of known transmission. OPHEH would conduct the investigation in collaboration with 

the medical center. 

On reviewing the final CRB recommendations, VACO senior leadership required further 

clarification regarding the specifics of its decision-making process and justification of its 

conclusions. In a letter dated December 14, 2010, the PDUSH requested that the CRB 

specifically address additional issues, including: how it chose the 1992 date, whether 

other dates were considered, and whether it considered the availability of electronic 

versus paper records; what was its estimate of risk to patients and was it quantified; what 

information should be disclosed and to provide evidence supporting disclosed 

information; did it consider input from the OGC’s evaluation of the credibility of the 

witness’ testimony; did it consider the testimony of the dental residents; and, why did it 

defer the issue of employee risk assessment and disclosure to the local medical center and 

local public health officials rather than VISN leadership and OPHEH? 

The CRB met for a fourth and final time on December 17, 2010, to address the questions 

brought by the PDUSH regarding its decision-making process and risk assessments. It 

submitted a written response to the PDUSH on December 17, 2010. The Chair of the 

CRB then met with senior VACO staff to review and discuss its written response. On 

January 4, 2011, VACO senior management made the decision to proceed with a 

disclosure as recommended by the CRB’s final report. 

VA Office of Inspector General 16 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

The patient selection for notification was based on those patients who received invasive 

procedures performed by the subject dentist from January 1, 1992, to July 28, 2010. The 

invasive procedures were identified by Current Procedural Terminology (CPT) codes as 

defined by the criteria set by the CRB in its final report. An algorithm and process were 

developed that indentified 535 patients who met the CRB criteria for disclosure. At the 

time of this report, chart reviews of another 150 patients were pending, which may 

indentify a small number of additional patients who should be notified. 

C. Conclusions Regarding the CRB 

We found that the CRB acted in good faith to address the potential risks to VA patients. 

The CRB incorporated an extensive amount of data from which to base its decisions. All 

recommendations were carefully considered, with input from a solid counsel of national 

subject area experts. The fact that its deliberations extended over 4 months is a testament 

to the daunting task of integrating sometimes conflicting data to formulate 

recommendations that would impact such a large patient population in an area in which 

there are not precise guidelines. 

The CRB was thorough in implementing its initial and subsequent charges and directives. 

Its recommendations appropriately followed VHA’s notification for disclosure policy. 

The changing nature of its reports and recommendations reflect the complexity of the 

underlying issues surrounding infectious diseases, the ethics of disclosure, and public 

health risk assessments. In formulating its recommendations, the CRB insisted on 

transparency and fully considered any potential risk of harm to patients. 

Issue 5: Staffing and Workplace Environment 

Our oversight review included evaluation of selected aspects of the daily functioning of 

the dental clinic and its management oversight. These review areas included staffing 

levels, work environment, and senior management oversight. 

A. Staffing and VHA Response 

The dental clinic is staffed by dentists, dental assistants, and dental hygienists. The clinic 

also has an accredited dental residency program. A VHA study evaluated the impact of 

dental staffing ratios on staff dentists’ productivity. The VHA study recommends 

1.5 dental assistants per dentist as optimal in clinics with residency training. In addition, 

the VA Assistant Under Secretary for Health for Dentistry and the current Acting Chief 

of Dental Service informed us that a ratio of 1.5 is optimal in clinics with dental 

residents. A review of the dental clinic staffing levels revealed they were below 

organizational approved FTE levels and also below the cited optimal ratio of 1.5. Efforts 

by the current Chief of Dental Service to recruit and fill vacant dental assistant positions 

were not fully supported by the medical center with necessary funding even though the 

Chief of Dental Service cited an impact on safety and infection control issues. This 

VA Office of Inspector General 17 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

occurred during a period of time when the medical center was under a facility-wide 

“Controlled Hiring Plan” to reduce cost and operate within funding levels. Limited 

dental assistant positions were approved for hiring coupled with the expectation that the 

number of dental residents would be reduced to address the impact on safety. 

B. Conclusions Regarding Staffing and VHA Response 

We found that the staffing levels at the dental clinic were persistently below their 

organizational approved FTE levels and the level recommended by VHA for optimal 

performance. Optimal staffing may have decreased the likelihood that deviations from 

approved infection control practices would occur. Medical center administration did not 

fully support efforts to staff the dental clinic at these optimal ratios. 

C. Work Environment 

During our dental clinic staff interviews, employees discussed concerns as to work 

climate and morale. We heard multiple concerns regarding ongoing staff shortages, 

favoritism, and demeaning comments to staff. We were told of staff altercations that 

resulted in formal police investigations. We found indications that interpersonal staff 

relations were strained, which negatively impacted the dental clinic. 

Recommendations 

Recommendation 1: We recommended that the VISN 10 Director review the findings 

related to the Dayton Dental Clinic, to include staffing issues, and take whatever action 

deemed appropriate. 

Recommendation 2: We recommended that the VISN 10 Director ensure that the 

Dayton Medical Center Director requires the Dental Service to comply with the relevant 

infection control policies. 

VA Office of Inspector General 18 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Comments 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided an acceptable action plan (see Appendixes A and B, pages 20–22, for the 

Directors’ comments). 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 Office of Inspector General 19 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 March 28, 2011 

From:	 Director, VA Healthcare System of Ohio (10N10) 

Subject:	 Healthcare Inspection – Oversight Review of Dental Clinic 

Issues, Dayton VA Medical Center, Dayton, Ohio 

To:	 Assistant Inspector General, Office of Healthcare Inspections 

Thru:	 Director, Management Review Service (10B5) 

1. The subject report, “Healthcare Inspection—Oversight 

Review of the Dental Clinic Issues, Dayton VA Medical 

Center, Dayton, Ohio” has been carefully reviewed by 

VISN l0 leadership. The report is thorough and reflects the 

facts as we know them to be. I appreciate the extensive 

review and work of the OIG team and their professional 

interactions throughout the review. 

2. VISN 10 concurs with the report findings and 

two recommendations. 

(original signed by:) 

Jack G. Hetrick, FACHE
 

Director, VA Healthcare System of Ohio (10N10)
 

VA Office of Inspector General 20 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 March 28, 2011 

From:	 Director, Dayton VA Medical Center (552/00) 

Subject:	 Healthcare Inspection – Oversight Review of Dental Clinic 

Issues, Dayton VA Medical Center, Dayton, Ohio 

To:	 Director, VA Healthcare System of Ohio (10N10) 

I have reviewed the “Healthcare Inspection – Oversight 

Review of Dental Clinic Issues, Dayton VA Medical Center, 

Dayton, Ohio”, report and concur with the two 

recommendations. A plan to finalize corrective actions is 

underway. 

(original signed by:) 

William Montague, FACHE
 

Director, Dayton VA Medical Center (552/00)
 

VA Office of Inspector General 21 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Director’s 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’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the VISN 10 Director review 

the findings related to the Dayton Dental Clinic, to include staffing issues, 

and take whatever action deemed appropriate. 

Concur Target Completion Date: June 30, 2011 

Medical Center’s Response: 

Complete administrative actions against parties responsible for appropriate 

infection control practices and oversight. Modify Dental Service 

organizational structure and assigned FTE levels to enhance clinical 

operations oversight and improve dental assistant staffing ratios. 

Implement actions resulting from Veterans Health Administration (VHA) 

National Center of Organizational Development (NCOD) Dental Service 

Workforce Reassessment to include the facilitation of the team building 

CREW (Civility, Respect, and Engagement in the Workplace) initiative. 

Personnel administrative actions and staffing level adjustments are being 

addressed and close to resolution. 

Recommendation 2. We recommended that the VISN 10 Director ensure 

that the Dayton Medical Center Director requires the Dental Service to 

comply with the relevant infection control policies. 

Concur Target Completion Date: May 30, 2011 

Medical Center’s Response: 

All Dental Service mandatory infection control training will be entered and 

tracked for compliance in the Dayton VAMC Learning Management 

System (LMS). Periodic random audits of Infection control training 

compliance, observations (e.g., hand hygiene, wearing PPE, etc.), and staff 

knowledge infection control checklist will be documented in the Dental 

Dashboard. 

VA Office of Inspector General 22 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Acknowledgments	 George B. Wesley, MD 

Monika Gottlieb, MD 

Kathleen Shimoda, RN 

Toni Woodard 

Simonette Reyes, RN 

Thomas Jamieson, MD, JD 

Maureen Reagan, RN, JD 

VA Office of Inspector General 23 
Oversight Review of Dental Clinic Issues, Dayton VA Medical Center, Dayton, Ohio 

Appendix D 

Report Distribution
	

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Healthcare System of Ohio (10N10) 

Director, Dayton VA Medical Center (552/00) 

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: Sherrod Brown, Rob Portman 

U.S. House of Representatives: Steve Austria, John A. Boehner, Jim Jordan, Mike Pence, 

Michael Turner 

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

VA Office of Inspector General 24