Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections
 

Report No. 11-02084-01

Combined Assessment Program
 

Review of the
 

Orlando VA Medical Center
 

Orlando, Florida
 

October 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 Orlando VA Medical Center, Orlando, FL 

Glossary

C&P credentialing and privileging 

CAP Combined Assessment Program 

DBC Disruptive Behavior Committee 

EN enteral nutrition 

EOC environment of care 

facility Orlando VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

MH mental health 

MSDS Material Safety Data Sheet 

OIG Office of Inspector General 

QM quality management 

RN registered nurse 

RRTP residential rehabilitation treatment program 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Table of Contents
 

Page

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

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

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

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

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

Results ........................................................................................................................ 3
 

Review Activities With Recommendations .............................................................. 3
 

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

Continuity of Care.............................................................................................. 4
 

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

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

Review Activities Without Recommendations ......................................................... 5
 

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

QM..................................................................................................................... 6
 

RN Competencies ............................................................................................. 6
 

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

Appendixes

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

B. VHA Satisfaction Surveys.................................................................................. 8
 

C. VISN Director Comments .................................................................................. 9
 

D. Facility Director Comments ............................................................................... 10
 

E. OIG Contact and Staff Acknowledgments ......................................................... 14
 

F. Report Distribution............................................................................................. 15
 

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

Review of the Orlando VA Medical Center, Orlando, FL

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

August 8, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

 Enteral Nutrition Safety 

 Quality Management 

 Registered Nurse Competencies 

The facility’s reported accomplishments 

were the military honors ceremony upon 

the death of a veteran in the hospice 

unit and the development and 

implementation of a system that has 

reduced the response time for team 

assistance in the management of a 

suicide call. 

Recommendations: We made 

recommendations in the following four 

activities: 

Environment of Care: Complete annual 

N95 respirator fit testing for designated 

employees, and monitor compliance. 

Document daily inspections of Mental 

Health Residential Rehabilitation 

Treatment Program residents’ rooms for 

unsecured medications, and monitor 

compliance. Ensure that Material Safety 

Data Sheet inventory lists and 

hazardous material information sheets 

are current and complete. 

Continuity of Care: Ensure that 

providers follow up with patients 

discharged from community hospitals. 

Require patients referred to non-VA 

providers to receive care within 30 days. 

Management of Workplace Violence: 

Ensure all incidents of threatening or 

disruptive behavior are referred to the 

Disruptive Behavior Committee. 

Physician Credentialing and Privileging: 

Report results of completed Focused 

Professional Practice Evaluations for all 

newly hired physicians to the 

Professional Standards Board. 

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 Orlando VA Medical Center, Orlando, FL 

Objectives and Scope
 

Objectives
 

Scope
 

CAP reviews are one element of the OIG’s efforts to ensure 

that our Nation’s veterans receive high quality VA health 

care services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 Continuity of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through August 8, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. 

During this review, we also presented crime awareness 

briefings for 306 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments
 Hospice Military

Honors Ceremony

Suicide Alert

Veterans

Emergency System

Military honors ceremonies are held upon the death of a 

veteran in the hospice unit. The veteran’s picture and 

branch of service are placed on the Memorial Wall, and the 

body is draped with the American flag. A public 

announcement is made honoring the service of the veteran, 

and there is a procession through the community living 

center with veterans, staff, and family as honorary 

pallbearers. All attending veterans salute at the Memorial 

Wall as the national anthem is played. The ceremony 

includes readings, the playing of Taps, and a final 

procession. 

Personalized sympathy cards are sent to the family from the 

facility’s Director, the chaplain, and executive and community 

living center staff. The chaplain follows up with the family a 

few days after the ceremony to offer further assistance. The 

veteran’s name, dates of birth and death, and branch of 

service are engraved on a gold leaf on the Memorial Tree, 

and the family is invited to view the tree. This dignified and 

respectful celebration of life has been very well received by 

the families of those veterans so honored. 

Telecare staff provide telephone advice to patients who call 

in. The Telecare Suicide Redesign work group developed a 

plan to improve the response time for managing a call from a 

suicidal patient and reduce the time for rescue action. 

Working with information technology staff, the group 

developed a desktop icon that is placed on telecare 

computers. Staff click on this icon while they are on the 

phone with a patient in crisis, and an instant message with 

applicable details is sent out. This allows one staff member 

to remain on the phone while another staff member goes for 

help. 

Results show that the elapsed time from a suicidal patient’s 

call to team assistance in the management of the call has 

decreased from 5 minutes to 10 seconds, and rescue 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

assistance now arrives at the patient’s home within 

25 minutes. Implementation of the Suicide Alert Veterans 

Emergency System was a cost effective way to improve 

patient safety. 

Results

Review Activities With Recommendations

EOC The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements and whether the 

Domiciliary Care for Homeless Veterans and Substance 

Abuse RRTPs complied with selected MH RRTP 

requirements. 

We inspected the ambulatory surgery and post-anesthesia 

areas; three community living center units; and the MH, 

wound care, infusion, dental, and women’s clinics. We also 

inspected the Domiciliary Care for Homeless Veterans and 

Substance Abuse RRTP units. The facility maintained a 

generally clean and safe environment. However, we 

identified the following conditions that needed improvement. 

Infection Control. The Occupational Safety and Health 

Administration requires facilities using N95 respirators to fit 

test designated employees annually. We reviewed 

17 employee records and determined that 7 designated 

employees did not have the required annual fit testing. 

MH RRTP Daily Medication Inspections. VHA requires that 

resident rooms be inspected daily for unsecured 

medications.1 We reviewed documentation of daily resident 

room inspections for unsecured medications for 4 randomly 

selected weeks from the months of February, March, and 

April 2011. We found that unit staff were not consistently 

documenting that inspections were being conducted. 

Environmental Safety. The Occupational Safety and Health 

Administration and The Joint Commission require that 

facilities maintain current MSDS inventory lists and 

hazardous material information for chemicals used in clinical 

areas. We reviewed 11 MSDS inventory lists and hazardous 

material information sheets, and found that 5 were not 

current or complete. 

1 VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program (MH RRTP), 

May 26, 2009. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Recommendations
 

Continuity of Care

Recommendations

Management of

Workplace

Violence

1. We recommended that processes be strengthened to 

ensure that annual N95 respirator fit testing is completed for 

designated employees and that compliance is monitored. 

2. We recommended that processes be strengthened to 

ensure that daily inspections of resident rooms for unsecured 

medications are documented and that compliance is 

monitored. 

3. We recommended that processes be strengthened to 

ensure that MSDS inventory lists and hazardous material 

information sheets are current and complete. 

The purpose of this review was to evaluate whether VA 

patients hospitalized in non-VA facilities had appropriate 

post-discharge follow-up by VA providers and whether 

patients referred to non-VA providers for outpatient care 

were seen within the required timeframe. 

Post-Discharge Follow-Up. The Chief of Primary Care told 

us that she expected primary care providers to follow up with 

patients discharged from community hospitals. We reviewed 

the medical records of 20 patients who had been 

hospitalized in the community. We found that 3 of the 

20 patients did not receive post-hospitalization follow-up with 

their designated primary care or MH provider. 

Outpatient Care Referrals. VHA requires that patients 

referred for outpatient care be seen within 30 days.2 We 

reviewed the medical records of 17 patients who were 

referred to non-VA providers for outpatient care in the 

community. We found that 5 of the 17 patients did not 

receive care within 30 days. 

4. We recommended that processes be strengthened to 

ensure that providers follow up with patients discharged from 

community hospitals. 

5. We recommended that processes be strengthened to 

ensure that patients referred to non-VA providers receive 

care within 30 days. 

The purpose of this review was to determine whether the 

facility issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

2 VHA Directive 2006-041, Veterans Health Care Service Standards, June 27, 2006. 

VA OIG Office of Healthcare Inspections 4 
&

CAP Review of the Orlando VA Medical Center, Orlando, FL 

We reviewed the facility’s policy and training plan. We 

selected three assaults that occurred at the facility within the 

past 2 years, discussed them with managers, and reviewed 

applicable documents. We identified the following areas that 

needed improvement. 

DBC Referrals. Facility policy requires that the DBC collect 

and analyze all incidents of threatening and disruptive 

behavior. We reviewed three cases of assaults by patients 

and found that two cases were not referred to the DBC. 

Recommendation& 6. We recommended that processes be strengthened to 

ensure that all incidents of threatening or disruptive behavior 

are referred to the DBC. 

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

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 15 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following area that needed improvement. 

FPPE. Facility process requires that an FPPE be completed 

for all newly hired physicians and that results be reported to 

the Professional Standards Board. The five newly hired 

physicians whose profiles we reviewed did not have results 

of completed FPPEs reported to the Professional Standards 

Board. 

Recommendation& 7. We recommended that results of completed FPPEs for 

all newly hired physicians be reported to the Professional 

Standards Board. 

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. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

QM The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance 

with applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

RN Competencies The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies and processes, interviewed 

nurse managers, and reviewed initial and ongoing 

competency assessment and validation documents for RNs. 

We determined that the facility had established an effective 

process to ensure that RN competencies were assessed and 

validated and that actions were taken when deficiencies 

were identified. We made no recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes C 

and D, pages 9–13, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Appendix A

Facility Profile3

Type of Organization Outpatient medical center 

Complexity Level 1c 

VISN 8 

Community Based Outpatient Clinics Clermont, FL 

Daytona Beach, FL 

Leesburg, FL 

Kissimmee, FL 

Orange City, FL 

Viera, FL 

Veteran Population in Catchment Area 294,257 

Type and Number of Total Operating Beds:

 Psychosocial RRTP 60 

 Community Living Center/Nursing

Home Care Unit

118 

 Other None 

Medical School Affiliation(s) University of Central Florida College of 

Medicine 

Florida State University College of Medicine 

 Number of Residents 4.5 

Resources (in millions):

 Total Medical Care Budget

FY 2011 (through

July 2011)

$466 

Prior FY (2010)

$358 

 Medical Care Expenditures $297 $358 

Total Medical Care Full-Time Employee

Equivalents

Workload:

 Number of Station Level Unique

Patients

 Inpatient Days of Care:

o Acute Care

1,952 

83,928 

NA 

1,822 

88,661 

NA 

o Community Living

Center/Nursing Home Care Unit

25,421 38,294 

Hospital Discharges NA NA 

Total Average Daily Census (including all bed

types)

160 163 

Cumulative Occupancy Rate (in percent) 90 91 

Outpatient Visits 737,552 1,048,757 

3 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Appendix B

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 * 45.8 49.7 * 54.8 49.8 

VISN 64.7 56.5 56.4 68.1 56.6 58.2 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

* Facility does not provide inpatient care 

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

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

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

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2009 2010 2011

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY

OVERALL SATISFACTION Figure 1:

LEVEL OF SATISFACTION

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Appendix C

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: September 22, 2011 

From: Director, VA Sunshine Healthcare Network (10N8) 

Subject: CAP Review of the Orlando VA Medical C

FL

enter, Orlando,

To: Associate Director, 

Inspections (54SP) 

Bay Pines Office of Healthcare 

Director, Management 

Management Review) 

Review Service (VHA 10A4A4 

1.	 I have reviewed and concur with the findings and recommendations in 

the report of the Combined Assessment Program Review of the 

Orlando VA Medical Center, Orlando, Florida. 

2.	 Corrective action plans have been established with planned completion 

dates, as detailed in the attached report. 

Nevin M. Weaver, FACHE 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Appendix D

Facility Director Comments

Department of

Veterans Affairs& Memorandum

Date:& September 21, 2011 

From:& Director, Orlando VA Medical Center (675/00) 

Subject:& CAP Review of the Orlando VA Medical Center, Orlando,

FL

To:& Director, VA Sunshine Healthcare Network (10N8) 

1.	 We thank you for allowing us the opportunity to review and respond to 

the subject report. 

2.	 We concur with the conclusions and recommendations presented by 

the Office of the Inspector General. We present you with the plans of 

action designed to correct those areas for which recommendations 

were provided. 

(original signed by:) 

Timothy W. Liezert 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

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 

annual N95 respirator fit testing is completed for designated employees and that 

compliance is monitored. 

Concur 

9/30/11 

The OVAMC Respiratory Protection Program contains the plan for employees requiring 

respiratory protection. The list of employees, based on position, activity and other risk 

of exposure, was approved by the Safety Manager and the Infection Control 

Coordinator. Currently, OVAMC has 204 employees in the Respiratory Protection 

Program to include employees from CLC, specialty clinics, and the pulmonary, 

bronchoscopy, and endoscopy suites who received annual N95 fit testing as required. 

These employees are medically cleared prior to initial fit testing and are fit tested 

annually. To ensure reliability of the process is maintained, all fit testing records, actual 

fit testing and evidence of satisfactory medical clearance documentation from 

Occupational Health will be kept in the Safety Office. Fit testing is performed on an 

established basis each month. Ongoing compliance will be monitored in both the EOC 

Committee and in the Infection Control Program annual review, noting compliance with 

performing initial/ annual respirator fit testing. Results of fit testing will be tracked in the 

database and posted on a SharePoint. 

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

daily inspections of resident rooms for unsecured medications are documented and that 

compliance is monitored. 

Concur 

Completed 

The daily Domiciliary residential room inspection log was revised to clearly separate and 

identify the components. The daily inspection log distinguishes (1) the daily room 

inspection for unsecure medications conducted each evening and (2) the resident 

accountability checks that are conducted each a.m. (6:00 a.m.) and p.m. (11:30 p.m.). 

The Domiciliary Tech. ensures that the log is completed daily for each of the above 

items and quality process reviews are conducted wherein the daily log is reviewed 

during morning report. Weekend logs are reviewed during the Monday morning report. 

The Program Director ensures compliance and monitoring with the daily inspections. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

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

MSDS inventory lists and hazardous material information sheets are current and 

complete. 

Concur 

10-31-11 

Three MSDS binders (CLC) out of six were corrected the same day of the finding. The 

remaining MSDS binders were corrected within the same week. To ensure immediate 

compliance to the process, all services were notified to ensure MSDS binders have both 

the up-to-date inventory sheets and corresponding MSDSs. Each year an annual 

update of chemical inventory with accompanying MSDS forms is performed by the 

service and submitted to the Safety Office. Ongoing compliance of MSDS books for 

current documentation will be conducted during scheduled EOC rounds. 

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

providers follow up with patients discharged from community hospitals. 

Concur 

Completed 

Integrated Health Service/Care Management has provided and will continue to expand 

on communicating the potential discharges of patients from community hospitals to all of 

the OVAMC Chief Medical Officers and the Chief of Primary Care (PC) via a list with 

patients and anticipated or actual discharge date. The report is also designed to 

highlight any patient that has a pending appointment over 3 days to ensure timeliness of 

post discharge appointment. The process to ensure follow up includes the assigned PC 

team/service coordinating the patient’s post discharge appointment, using this list, with 

either a face-to-face or telephone contact visit with the patient and assigned Primary 

Care Provider or Team Liaison within 2-7 days post discharge. A process review will 

begin Quarter 1 FY 12 with a review of Quarter 4 FY 11 data to monitor performance. 

This ongoing monitoring of the process and review/audit of charts will ensure that 

coordination has occurred from discharge to post-discharge appointment/visit. 

Recommendation 5. We recommended that processes be strengthened to ensure that 

patients referred to non-VA providers receive care within 30 days. 

Concur 

Completed 

IHS/Non-VA Purchased Care will continue to monitor and trend consult referrals to Fee 

Basis from the time of receipt of service until service completion. Monitoring of this data 

is maintained in a tracking tool. In order to ensure compliance, concurrent review of the 

tracking tool is performed. The consults are tracked by use of the clinical tracking tool 

for the high risk services. The data are trended monthly with accompanying graphs. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Consult completion time is also tracked and trended. A process review will begin 

Quarter 1 FY 12 with a review of Quarter 4 FY 11 data to monitor performance. This 

ongoing monitoring of the process and review/audit of charts will ensure that 

coordination of referrals to non-VA providers for care within 30 day time frame is met 

and consults are closed out. 

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

all incidents of threatening or disruptive behavior are referred to the DBC. 

Concur 

Completed 

The Disruptive Behavior Committee is now reviewing all patient/patient-patient/patientemployee assaults as they are reported. The process to ensure all reports are received 

was strengthened by (a) re-education to all Committee members; (b) review of reporting 

process with Police; and (c) reinforcement of reporting in the CLC with long term 

patients that may exhibit disruptive behaviors. Reports have increased and now include 

additional reports from the CLC and Police. OVAMC police are reporting all relevant 

assaults to the DBC on an ongoing basis. This information is reviewed and addressed 

by the Committee as a recurring agenda item. Four new patient record flags have been 

assigned as a result of last month’s reports and consideration by the DBC. 

Recommendation 7. We recommended that results of completed FPPEs for all newly 

hired physicians be reported to the Professional Standards Board. 

Concur 

Completed 

FPPE due dates for all newly hired physicians are recorded in the Professional 

Standards Board (PSB) minutes. The names of the providers and the FPPE due dates 

will remain on the PSB agenda for monitoring compliance until completed results are 

submitted to the credentialing office in accordance with policy. Bi-weekly reminders are 

sent to the Service Chiefs and Chief of Staff for the respective provider(s) until 

submission of the completed FPPE. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Appendix E

OIG Contact and Staff Acknowledgments

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors Carol Torczon, MSN, ACNP, Project Leader 

David Griffith, RN, FAIHQ 

Karen McGoff-Yost, LCSW, MSW 

Alice Morales-Rullan, MSN, CNS 

Christa Sisterhen, MCD 

William Chirinos, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Orlando VA Medical Center, Orlando, FL 

Appendix F

Report Distribution

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Sunshine Healthcare Network (10N8) 

Director, Orlando VA Medical Center (675/00) 

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: Bill Nelson, Marco Rubio 

U.S. House of Representatives: Daniel Webster 

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

VA OIG Office of Healthcare Inspections 15