Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
	

Report No. 11-00032-213 

Combined Assessment Program
	

Review of the
	

VA Southern Oregon
	

Rehabilitation Center and Clinics
	

White City, Oregon
	

July 7, 2011
	

Washington, DC 20420
	
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal activity to 

the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CLC community living center 

COC continuity of care 

ECMS Executive Committee of the Medical Staff 

EOC environment of care 

facility VA Southern Oregon Rehabilitation Center and 

Clinics 

FY fiscal year 

MCM medical center memorandum 

MEC Medical Executive Committee 

MH RRTP Mental Health Residential Rehabilitation Treatment 

Program 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

PCP primary care provider 

PI performance improvement 

PR peer review 

QM quality management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Table of Contents
	

Page 

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

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

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

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

Reported Accomplishment........................................................................................ 2
 

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

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

QM..................................................................................................................... 2
 

Management of Test Results............................................................................. 3
 

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

EOC................................................................................................................... 4
 

Review Activity Without Recommendations............................................................ 4
 

COC .................................................................................................................. 4
 

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

Appendixes 

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

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

C. VHA Satisfaction Surveys ................................................................................. 8
 

D. VISN Director Comments .................................................................................. 9
 

E. Acting Facility Director Comments..................................................................... 10
 

F. OIG Contact and Staff Acknowledgments ......................................................... 15
 

G. Report Distribution ............................................................................................ 16
 

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

Review of the VA Southern Oregon 

Rehabilitation Center and Clinics, White City, OR 

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 

March 7, 2011. 

Review Results: The review covered 

five activities. We made no 

recommendations in the following 

activity: 

 Continuity of Care 

The facility’s reported accomplishment 

was an extensive veteran Native 

American program. 

Recommendations: We made 

recommendations in the following four 

activities: 

Quality Management: Ensure that peer 

review findings are reported to the 

Medical Executive Committee quarterly 

and that medical record quality reviews 

include monitoring of unauthenticated 

documentation. 

Management of Test Results: Ensure 

diagnostic clinicians consistently 

document the time critical results were 

communicated to ordering providers. 

Communicate normal test results to 

residents within the specified timeframe, 

and document communication in the 

medical record. 

Physician Credentialing and Privileging: 

Ensure Ongoing Professional Practice 

Evaluations contain specific measurable 

performance data to support physician 

reprivileging. 

Environment of Care: Implement and 

document daily inspections for 

unsecured medications. 

Comments 

The Veterans Integrated Service 

Network and Acting Facility Directors 

agreed with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

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 five activities: 

	 COC 

	 EOC 

	 Management of Test Results 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through March 7, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on selected recommendations 

from our prior CAP review of the facility (Combined 

Assessment Program Review of the VA Southern Oregon 

Rehabilitation Center and Clinics, White City, Oregon, Report 

No. 08-00988-181, August 13, 2008). (See Appendix B for 

further details.) The facility had one repeat QM finding. 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

During this review, we also presented crime awareness 

briefings for 297 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishment
	 Veteran Native		 The facility provides veterans the opportunity to pursue an 

American Program understanding of Native American spirituality and culture. 

Minority veteran volunteers and Native American elders 

share tribal knowledge and direct the culturally diverse 

programs. 

Results 

Review Activities With Recommendations 

QM		 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement. 

PR. VHA requires that PR results be reported to the MEC on 

a quarterly basis.1 We found that results were discussed at 

the MEC in only 2 of the past 4 quarters. This was a repeat 

finding from the previous CAP review. 

Medical Records Quality Review. VHA requires that health 

record reviews include monitoring of unauthenticated 

documentation.2 We found that these reviews did not 

include the monitoring of unsigned progress notes, discharge 

summaries, and histories and physical exams. 

1 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 2 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Recommendations		 1. We recommended that PR findings be reported to the 

MEC quarterly. 

2. We recommended that medical record quality reviews 

include the monitoring of unauthenticated documentation. 

Management of		 The purpose of this review was to follow up on a previous 

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.3 

We reviewed the facility’s policies and procedures and we 

reviewed medical records. We identified the following areas 

that needed improvement. 

Documentation of Ordering Provider Notification. VHA 

requires that diagnostic laboratory and radiology clinicians 

document in the medical record the time and means of 

critical test result communication and the name of the 

ordering provider contacted.4 We reviewed the medical 

records of 20 residents who had critical results and found 

that diagnostic clinicians did not document the time the 

ordering provider was notified in 11 of the 20 records. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to residents no later than 

14 calendar days from the date that the results were 

available to the ordering provider.5 We reviewed the medical 

records of 20 residents who had normal results and found 

that 8 of the 20 records did not contain documentation that 

the facility had communicated the results to the residents. In 

addition, we found that of the 12 residents who were notified, 

three notifications did not occur within the required 14-day 

timeframe. 

Recommendations		 3. We recommended that diagnostic clinicians consistently 

document the time critical results were communicated to 

ordering providers. 

4. We recommended that normal test results be 

consistently communicated to residents within the specified 

timeframe and documented in the medical record. 

3 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 4 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 5 VHA Directive 2009-019.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

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 four 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. 

OPPE. VHA policy requires specific competency criteria in 

OPPEs for all privileged physicians.6 We did not find specific 

measurable performance data to support reprivileging in 

three of the four C&P files and profiles reviewed. 

Recommendation 5. We recommended that OPPEs contain specific 

measurable performance data to support physician 

reprivileging. 

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. 

We inspected the infirmary and residential care units, 

including women residents’ rooms, for safety and security. 

We evaluated the infirmary and the residents’ rooms for 

compliance with VHA’s MH RRTP policy for safe medication 

management. The facility maintained a generally clean and 

safe environment. However, we identified the following area 

that needed improvement. 

Daily Medication Inspections. VHA requires that resident 

rooms be inspected daily for unsecured medications.7 The 

facility was not conducting these inspections. 

Recommendation 6. We recommended that daily inspections for unsecured 

medications be implemented and documented. 

Review Activity Without Recommendations
	

COC		 The purpose of this review was to determine whether 

communication between community hospitals and the facility 

occurred when facility residents were hospitalized in the 

community. Such communication is essential to continuity of 

care and optimal resident outcomes. In addition, we looked 

6 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 7 VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program (MH RRTP),
 

May 26, 2009.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

for evidence to determine whether PCPs acknowledged and 

documented resident hospitalizations. 

We reviewed the medical records of 13 residents who were 

hospitalized at VA expense in the local community from 

February 2010 to December 2010. We determined that the 

facility generally met requirements in these areas. We made 

no recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 9–14, 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 5 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix A 

Facility Profile8 

Type of Organization Residential rehabilitation center and 

outpatient clinics 

Complexity Level 3 

VISN 20 

Community Based Outpatient Clinic Klamath Falls, OR 

Veteran Population in Catchment Area 46,140 

Type and Number of Total Operating Beds: 

 Domiciliary Residential Rehabilitation 

Treatment Program 

 Domiciliary Care Homeless Veterans 

546 

54 

 CLC/Nursing Home Care Unit 0 

 Other 0 

Medical School Affiliation(s) Eastern Washington University, Spokane, 

WA 

Oregon Health and Science University, 

Portland, OR 

Others 

 Number of Residents 0 (No residency program) 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

January 2011) 

$85.8 

FY 2010 

$88.5 

 Medical Care Expenditures $28.6 $87.5 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

566.10 

10,737 

0 

559.57 

16,250 

0 

o CLC/Nursing Home Care Unit 0 0 

MH RRTP Discharges 181 (Community) 758 (Community) 

Total Average Daily Census (including all bed 

types) 

398.42 425.58 

Cumulative Occupancy Rate (in percent) 82.49 88.11 

Outpatient Visits 36,479 189,814 

8 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Consistently trend, analyze, and routinely 

report QM data to the appropriate oversight 

group. 

Committee minutes have been 

restructured. In-service training was 

completed September 22–23, 2008. 

The MCM was uploaded for staff on 

October 10, 2008. 

Y N 

2. Ensure that the PI plan includes the role 

of the ECMS in QM and that clinical reviews 

are reported to that committee. 

The committee developed an MCM for 

the new MEC and sent it out for 10-day 

concurrence. The MCM was 

implemented by October 1, 2008. 

Y N 

3. Implement a process to trend and 

analyze PR findings, and report aggregated 

results quarterly to the ECMS. 

A spreadsheet for trending and 

analyzing PR data was implemented 

July 25, 2008. However, the 

ECMS/MEC is not reviewing 

aggregated reports quarterly. 

N Y (see pages 2–3) 

4. Require timely completion of mortality 

case reviews, and implement standardized 

trending, analysis, and reporting of this data 

in accordance with VHA policy. 

A spreadsheet for trending and 

tracking mortality data was 

implemented July 26, 2008. This 

information is reported quarterly to 

MEC. 

Y N 

Pharmacy Operations 

5. Implement a requirement that annual 

training for controlled substances inspectors 

be conducted and documented. 

Controlled substance inspectors’ 

training records contain documentation 

of annual training. 

Y N 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix C 

VHA Satisfaction Surveys
	 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Inpatient 

Score 

Quarter 4 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Facility NA NA NA NA 55.2 45.8 50.2 51.3 

VISN 61.2 65.7 68.8 65.5 49.6 49.7 50.0 50.1 

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4 

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

scores for 2008, 2009, and 2010. 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 

2008 2009 2010 

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 VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: 06/10/2011 

From: Network Director, VISN 20 (10N20) 

Subject: CAP Review of the VA Southern Oregon Rehabilitation 

Center and Clinics, White City, OR 

To: Director, Seattle Office of Healthcare Inspections (54SE) 

Director, Management Review Service (VHA CO 10B5 Staff) 

1. Thank you for the opportunity to provide a status report on the draft 

findings from the Combined Assessment Program Review of the VA 

Southern Oregon Rehabilitation Center and Clinics, White City, Oregon. 

2. Attached please find the facility concurrences and responses to each of 

the findings from the review. 

3. If you have additional questions or need further information, please 

contact Susan Gilbert, Survey Coordinator, VISN 20 at (360) 567-4678. 

(original signed by:) 

Susan Pendergrass, DrPH 

VA OIG Office of Healthcare Inspections 9 
A

tions

1

ec

iew of the

d Clinics

Nor

Southern Oregon Rehabilitation Center & Clinics

to express my appreciation to the Office of

I

ssment Program (CAP) review conducted

the report we have reviewed and updated and

ddressing each recommendation are attached.

tions that are in progress and those that have

ted.

pportunity for the review as a continuing process to

ovide for our Veterans.

cs, White City, OR

Acting

Office of Healthcare Inspe

Veterans Affai

06/07/20

Di

CAP Re ilitation

Center a

Director,

On behalf of the V Clinics

(SORCC), I would li ffice of

nal and

Comprehensive Ass nducted

The findings fro ted and

SORCC’s responses ed.

nses include a at have

already been impleme

3. We appreciate the ocess to

improve the care we p

Southern Oregon Rehabilitation Center and Clin

Memorandu

VA Southern Oregon Reha

On behalf of the VA Southern Oregon Rehabilitation Center

(SORCC), I would like to express my appreciation to the

G) Survey Team for their professi

Comprehensive Assessment Program (CAP) review

The findings from the report we have reviewed and upd

SORCC’s responses addressing each recommendation are atta

nses include actions that are in progress and those t

3. We appreciate the opportunity for the review as a continuing p

CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix E 

Acting Facility Director Comments 

Department of 

Veterans Affairs		 Memorandum 

Date:		 06/07/2011 

From:		 Acting Director (692/00), SORCC 

Subject:		 CAP Review of the VA Southern Oregon Rehabilitation 

Center and Clinics, White City, OR 

To:		 Director, Northwest Network (10N20) 

1. On behalf of the VA Southern Oregon Rehabilitation Center & Clinics 

(SORCC), I would like to express my appreciation to the Office of 

Inspector General (OIG) Survey Team for their professio and nal 

Comprehensive Assessment Program (CAP) review conducted 

March 7–10, 2011. 

2. The findings from the report we have reviewed and updated and 

SORCC’s responses addressing each recommendation are attached. The 

responses include actions that are in progress and those that have 

already been implemented. 

3. We appreciate the opportunity for the review as a continuing process to 

improve the care we provide for our Veterans. 

David Donnelly, MD 

VA OIG Office of Healthcare Inspections	 10 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

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 PR findings be reported to the MEC 

quarterly. 

Concur 

Target date for completion: Peer Review Reports will be reported at the first of each 

quarter to MEC. If the meeting is cancelled the report will be forwarded to the agenda 

for the next month. The process will begin immediately. 

Facility’s response: 

1.	 Before FY2009 we did not have a process to aggregate and analyze Peer Review 

Data. The aggregation of data and analysis is a continuous process, which has 

been in place since October 1, 2008. 

2.	 In FY 09 the data was reported to the MEC quarterly, however due to meeting 

cancellations the data was not reported quarterly to the MEC in FY2010. The same 

data was reported to the Quality Leadership Committee (QLC). The Chief of Staff 

and senior executives are members to this committee and they did review and 

analyze the data on a quarterly basis. 

3.	 Adjustments have been made to identify reports that must be reported quarterly to 

the MEC, and this particular report will be presented at the beginning of each 

quarter. This will allow time to report the data within the quarter, if the first meeting 

is cancelled. 

Recommendation 2. We recommended that medical record quality reviews include the 

monitoring of unauthenticated documentation. 

Concur 

Target date for completion: Per VHA Directive 1907.01 (Health Information 

Management and Health Records), and MCM 136-005 (Medical Record 

Documentation), a quality review monitor will be officially established June 1, 2011. 

Facility’s response: We have a process in place that monitors daily discharge 

summaries and history & physical exams. The results are reported monthly to our 

Performance Enhancement Team (PET) Committee. We have been deficient in a 

process to report audited unsigned progress notes. The new process will address 

unsigned progress notes by providers and will be reported at the beginning of each 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

month and sent to the PET. The report will provide unsigned notes by the number of 

days delinquent; i.e. for the Month of January: 5 notes were 1 to 3 days delinquent; 

65 notes were 4 to 7 days delinquent; 58 notes were 8 to 14 days delinquent and so on. 

Additionally, trends (by provider) that are noted will be addressed to the PET for review. 

In conducting this review each provider (on a monthly basis) will be sent via encrypted 

Outlook message, a list of their unsigned progress notes in order to allow the 

provider(s) a chance to sign them at the time the quality review is conducted. 

Recommendation 3. We recommended that diagnostic clinicians consistently 

document the time critical results were communicated to ordering providers. 

Concur 

Target date for completion: June 1, 2011 

Facility’s response: 

1.	 Critical lab results are entered into the Veteran’s medical record through a laboratory 

template for critical results. The template entries include the date and time when the 

critical results are communicated, by what means the results were communicated, 

who was contacted and received the results (i.e. ordering provider) and the initials of 

the laboratory technologist that made the notification/communication. 

2.	 At the time of the OIG CAP survey, Radiology did not have a system in place that 

documented that time critical results were conveyed to the ordering provider. 

SORCC has since implemented a new process whereby an entry is made into the 

Veteran’s electronic medical record that will include the name of the provider who 

receives the notification, date, time and means of communication of the critical test 

result as part of the reporting process. 

3.	 In addition to the data and analysis Laboratory and Radiology submit quarterly to the 

MEC, they will include audits that demonstrate compliance in documentation 

concerning critical results were communicated and documented in the Veteran’s 

electronic medical record. This additional information will be reported by the FY2011 

fourth quarter. 

Recommendation 4. We recommended that normal test results be consistently 

communicated to residents within the specified timeframe and documented in the 

medical record. 

Concur 

Target date for completion: An Improvement Team is currently in progress. A system 

will be in place to report normal test results to the residents by August 1, 2011 and the 

data collection and analyze to be reported in the new fiscal year, starting Oct. 1, 2011. 

Facility’s response: A performance improvement work group consisting of 

stakeholders has been implemented to develop a means to communicate posted 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

normal lab results to our residents within 14 days. The processes this team develops 

will be implemented by August 1, 2011. In our facility quarterly medical record chart 

reviews will include audits to identify if these normal test results are consistently 

communicated and documented with the specified time frame. The data collected will 

be presented to Performance Enhancement Team (PET) quarterly beginning in the new 

fiscal year, October 1, 2011. 

Recommendation 5. We recommended that OPPEs contain specific measurable 

performance data to support physician reprivileging. 

Concur 

Target date for completion: Process was completed and implemented April 1, 2011 

Facility’s response: During the OIG visit the new process for OPPEs had been 

developed but not implemented. Subsequently the process has been fully 

implemented. Risk Management does 10% spot checks per quarter for Dental and 

Pharmacy Services and bi-annual spot checks for Medicine and Psychiatry. OPPE is 

reviewed prior to re-privileging. 

Recommendation 6. We recommended that the daily inspections for unsecured 

medications be implemented and documented. 

Concur 

Target date for completion: June 1, 2011 

Facility’s response: 

1.	 SORCC has included a process to look for unsecured medications in the twice daily 

bed checks at 6 a.m. and 10 p.m. The process is documented on the Bed Check 

Roster Spreadsheet and a column specifically for unsecure medication is provided 

for documentation. This data will be aggregated and reported quarterly to the 

Rehabilitation Executive Committee (REC). 

2.	 Currently, 10% of the residential rooms are randomly inspected on a weekly basis. 

These inspections will include unsecure medication checks and will be documented 

in the report. 

3.	 Inspections will be completed when a resident’s status changes (admitted to the 

Infirmary; transferred to another facility; lodged out of the facility or unaccounted for) 

and any unsecure medication will be noted and documented. 

4.	 We will add a column for unsecure medications during weekly medication and locker 

inspections. All unsecure medications found will be reported to the residential 

program coordinators. This information will be included in the Bed Check Roster 

Spreadsheet that is reported quarterly to the REC. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

5.	 Weekly Environmental Rounds includes a process to check unsecure medication. 

This data will be included in the Environmental Rounds Report. This report is 

presented to Quality Leadership Committee (QLC) at least quarterly. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Contributors Karen A. Moore, RN, Director, Seattle Regional Office, Project 

Leader 

Sarah Lutter, RN, JD, Team Leader 

Gail Bozzelli, RN 

Daniel Kolb, PhD 

Sami O’Neill, MA 

Mary Noel Rees, MPA 

Marc Lainhart, BS, Program Support Assistant 

Martin M. Davidson, Office of Investigations 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, OR 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Northwest Network (10N20) 

Acting Director, VA Southern Oregon Rehabilitation Center and Clinics (692/00) 

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: Jeff Merkley, Ron Wyden 

U.S. House of Representatives: Greg Walden 

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

VA OIG Office of Healthcare Inspections 16