Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections
 

Report No. 11-01608-273

Combined Assessment Program
 

Review of the
 

G.V. (Sonny) Montgomery
 

VA Medical Center
 

Jackson, Mississippi
 

September 8, 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 G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Glossary

ARB Accident Review Board

C&P credentialing and privileging

CAP Combined Assessment Program

CLC community living center

CPR cardiopulmonary resuscitation

DBC Disruptive Behavior Committee

EMR electronic medical record

EN enteral nutrition

EOC environment of care

facility G.V. (Sonny) Montgomery VA Medical Center

FY fiscal year

JC Joint Commission

MSDS material safety data sheet

OIG Office of Inspector General

PRC Peer Review Committee

PRF Patient Record Flag

QM quality management

RN registered nurse

UOR uniform offense report

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VA OIG Office of Healthcare Inspections
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CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Table of Contents
 

Page

Executive Summary ...................................................................................................

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

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

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

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

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

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

Management of Workplace Violence................................................................. 3

RN Competencies ............................................................................................. 4

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

Coordination of Care ......................................................................................... 6

EOC................................................................................................................... 7

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

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

Medication Management ................................................................................... 8

Physician C P................................................................................................... 8

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

Appendixes

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

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

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 13

D. VISN Director Comments .................................................................................. 15

E. Interim Facility Director Comments.................................................................... 16

F. OIG Contact and Staff Acknowledgments ......................................................... 20

G. Report Distribution ............................................................................................ 21

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

Review of the G.V. (Sonny) Montgomery VA Medical Center,
 

Jackson, MS
 

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

June 13, 2011.

Review Results: The review covered

eight activities. We made no

recommendations in the following

activities:

 Enteral Nutrition Safety

 Medication Management

 Physician Credentialing and

Privileging

The facility’s reported accomplishments

were a program to proactively track

patient fluoroscopy exposure and a

shortened preoperative testing protocol,

which has reduced costs and delays.

Recommendations: We made

recommendations in the following five

activities:

Management of Workplace Violence: 

Discuss violent incidents involving

employee victims at the Accident

Review Board. Ensure that the

Disruptive Behavior Committee’s

(DBC’s) decisions to place flags in the

medical record are carried out. Share

VA police uniform offense reports of

workplace violence with the DBC.

Registered Nurse Competencies: 

Identify actions in facility policy to

address registered nurse competency

deficiencies. Ensure that competency

validation documentation is complete

and that the methods used to assess

and validate competency are specified.

Specify the qualifications required to

assess and validate competency.

Quality Management: Include

documentation of completed corrective

actions in Peer Review Committee

minutes. Document risk assessments

prior to procedures involving moderate

sedation. Ensure all resuscitation

events are reviewed and documented in

Cardiopulmonary Resuscitation

Committee minutes.

Coordination of Care: Ensure advance

directive notification and screening are

accurately documented. Require

advance directives completed on the VA

form to be appropriately witnessed.

Environment of Care: Complete annual

N95 respirator fit testing for all

designated employees. Ensure material

safety data sheet inventory lists and

hazardous material information are

current.

Comments

The Veterans Integrated Service

Network and Interim 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
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CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Objectives and Scope
 

Objectives
 

Scope
 

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

that our Nation’s veterans receive high quality VA health care

services. The objectives of the CAP review are to:

	 Conduct recurring evaluations of selected health care

facility operations, focusing on patient care administration

and QM.

	 Provide crime awareness briefings to increase employee

understanding of the potential for program fraud and the

requirement to refer suspected criminal activity to the

OIG.

We reviewed selected clinical and administrative activities to

evaluate the effectiveness of patient care administration and

QM. Patient care administration is the process of planning

and delivering patient care. QM is the process of monitoring

the quality of care to identify and correct harmful and

potentially harmful practices and conditions.

In performing the review, we inspected selected areas,

interviewed managers and employees, and reviewed clinical

and administrative records. The review covered the

following eight activities:

	 Coordination of Care

	 EN Safety

	 EOC

	 Management of Workplace Violence

	 Medication Management

	 Physician C P

	 QM

	 RN Competencies

The review covered facility operations for FY 2010 and

FY 2011 through June 13, 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 OIG Office of Healthcare Inspections& 1
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

G. V. (Sonny) Montgomery VA Medical Center, Jackson, 

Mississippi, Report No. 08-03088-138, June 2, 2009). The

facility corrected all findings from the prior CAP review. (See

Appendix B for further details.)

During this review, we also presented crime awareness

briefings for 307 employees. These briefings covered

procedures for reporting suspected criminal activity to the

OIG and included case-specific examples illustrating

procurement fraud, conflicts of interest, and bribery.

In this report, we make recommendations for improvement.

Recommendations pertain to issues that are significant

enough to be monitored by the OIG until corrective actions

are implemented.

Reported Accomplishments
 Fluoroscopy

Tracking

Improved

Preoperative

Testing Protocol

The facility implemented a policy requiring fluoroscopy

technicians and their supervisors to track patients exposed to

radiation from procedures involving fluoroscopy. In

procedures where the radiation dose exceeds 600 rads1 (far

less than the dose required by The JC to be reported) or

where the procedure exposure time exceeds 75 minutes, the

Radiation Safety Officer is to be notified immediately to make

an estimate of patient exposure. Following a report of a case

that exceeds either trigger point, the Radiation Safety Officer

contacts the patient’s provider with instructions to observe

the exposed area. The Radiation Safety Officer maintains a

file of any resulting after effects. The policy also contains a

chart of expected tissue effects and a mechanism to consult

dermatology when indicated.

Anesthesia Service recognized the potential to reduce

avoidable costs by shortening the protocol for preoperative

testing. By decreasing the numbers of unnecessary

preoperative tests, Ophthalmology Service realized a total

cost savings of $77,000 for 101 procedures in April and

May 2011. In addition to the cost saving benefit, efficiency

has improved, and patient travel has been reduced.

1 A rad is a unit of measurement for absorbed radiation. 

VA OIG Office of Healthcare Inspections 2
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Results

Review Activities With Recommendations

Management of	 The purpose of this review was to determine whether VHA

Workplace facilities issued and complied with comprehensive policy

regarding violent incidents and provided required training. Violence

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.

ARB. VHA policy2 requires all violent incidents involving

employee victims to be discussed at the facility’s ARB. Of

the three assaults we reviewed, two involved employee

injury. Neither was discussed at the ARB.

PRFs. When perpetrators of violence are patients, VHA and

facility policy require that the DBC review violent incidents

and consider placement of a PRF in the EMR.3 This flag

alerts facility staff about potentially violent patients and may

provide instructions about what to do when the patient

comes to the facility. Patients were the perpetrators in the

three assaults we reviewed. The DBC determined that two

of these three patients should have a PRF placed in the

EMR. We found that neither of these flags was placed.

Therefore, staff were not alerted to the potential danger, and

the need for police escort for one of the patients was not

communicated to staff.

UORs. Facility policy requires that Police Service complete

UORs for incidents involving workplace violence and that

these reports be shared with the DBC. We were told that

although they were available, UORs had not been shared

with the DBC.

Recommendations	 1. We recommended that processes be strengthened to

ensure that all violent incidents involving employee victims

are discussed at the ARB and that compliance is monitored.

2. We recommended that processes be strengthened to

ensure that the DBC’s decisions to place PRFs in the EMR

are carried out and that compliance is monitored.

2 VHA Handbook 7701.01, Occupational Safety and Health (OSH) Program Procedures, August 24, 2010. 3 VHA Directive 2010-053, Patient Record Flags, December 3, 2010 (corrected copy). 

VA OIG Office of Healthcare Inspections& 3
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

RN Competencies

Recommendations

3. We recommended that Police Service routinely share

UORs for incidents involving workplace violence with the

DBC.

The purpose of this review was to determine whether the

facility had an adequate RN competency assessment and

validation process.

We reviewed facility policies and processes, interviewed

nurse managers, and reviewed initial and ongoing

competency assessment and validation documents for

12 RNs. We identified the following areas that needed

improvement.

Facility Competency Validation Process. The JC requires

that clinical staff be deemed competent to perform their job

responsibilities and that the facility takes action when staff

competency does not meet expectations. A competency

validation policy or process is required for staff who provide

patient care, treatment, or services. The facility’s

competency validation policy did not clearly identify actions

to be taken to correct deficiencies.

Competency Validation Methods and Documentation. The

JC requires facilities to specify the assessment methods

used (such as test taking, demonstration, or simulation) to

determine an individual’s competency in required skills. We

found that validation methods were not specified for the skill

being assessed and validated in 3 of the 12 competency

folders reviewed. Additionally, required employee and/or

validator signatures were missing in 5 of the 12 folders.

Competency Validation by Qualified Individuals. The JC

requires that competency be assessed and validated by an

individual with the appropriate education, experience, or

knowledge related to the skills being reviewed. Facility

processes did not consistently specify the qualifications

required for individuals who perform competency

assessment and validation.

4. We recommended that facility policy identify actions to

be taken when RN competency does not meet expectations.

5. We recommended that processes be strengthened to

ensure that RN competency validation documentation is

complete and that methods used to assess and validate

competency are specified.

VA OIG Office of Healthcare Inspections 4
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

6. We recommended that managers specify the

qualifications required for individuals who perform RN

competency assessment and validation.

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.

Peer Review. VHA requires that all Level 2 and 3 final peer

reviews have appropriate actions documented and tracked to

closure in PRC meeting minutes.4 The QM peer review

liaison received hand written notices of provider discussions.

However, we reviewed 11 cases and found no

documentation in the PRC meeting minutes that corrective

actions were completed.

Moderate Sedation. VHA requires that providers document a

complete history and physical within 30 days prior to an

outpatient procedure where moderate sedation will be used

and re-evaluate the patient immediately prior to sedation.5

These evaluations must include a review of overall risk

status. We reviewed the EMRs of 10 patients who received

moderate sedation and found that 2 EMRs did not contain

risk assessments.

CPR Committee. VHA requires that the CPR Committee

review each episode of care where resuscitation was

attempted and identify opportunities to improve both process

and outcomes.6 We found that the CPR Committee meeting

minutes for August 2010 through February 2011 did not

reflect a review of individual resuscitation events by the

committee.

Recommendations	 7. We recommended that processes be strengthened to

ensure that PRC minutes include documentation of

4 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 5 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006.
 6 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 

VA OIG Office of Healthcare Inspections& 5
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Coordination of

Care

completed corrective actions and that compliance is

monitored.

8. We recommended that processes be strengthened to

ensure that risk assessments are documented prior to

procedures requiring moderate sedation and that compliance

is monitored.

9. We recommended that processes be strengthened to

ensure that all resuscitation events are reviewed and

documented in CPR Committee meeting minutes and that

compliance is monitored.

The purpose of this review was to evaluate whether the

facility managed advance care planning and advance

directives in accordance with applicable requirements.

We reviewed patients’ medical records for evidence of

advance directive notification, advance directive screening,

and documentation of advance care planning discussions.

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

was consistent with VHA policy. We identified the following

areas that needed improvement.

Advance Directive Notification. VHA requires that patients

receive written notification at each admission to a VHA

facility regarding their right to accept or refuse medical

treatment, to designate a Health Care Agent, and to

document their treatment preferences in an advance

directive.7 As part of notification, patients must be informed

that VA does not discriminate based on whether or not they

have an advance directive. We reviewed the medical

records of 20 patients and found that 13 of the records did

not contain evidence of all components of written notification.

While we were onsite, the facility made changes to progress

note templates to better document this process.

Advance Directive Screening Accuracy. VHA requires that

staff screen patients at each admission to a VHA facility to

determine whether they have an advance directive and

document the screening in the medical record.8 Although

advance directive screenings were completed for the

20 patients whose medical records we reviewed, 4 of the

screenings were not accurate. These four screenings

documented that the patients had completed advance

7 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 8 VHA Handbook 1004.02. 

VA OIG Office of Healthcare Inspections 6
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Recommendation

EOC

directives and that they were scanned into the medical

record. However, we could not locate any of these advance

directives.

Management of Advance Directive Documents. VHA

requires the signature of two witnesses when advance

directives are executed on the VA form.9 We examined five

advance directives completed on the VA form and found that

one was not witnessed properly.

10. We recommended that processes be strengthened to

ensure that all components of advance directive notification

are documented, that advance directive screening is

accurately documented in the EMR, and that advance

directives completed on the VA form are appropriately

witnessed.

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 inpatient surgical, medical/surgical, and

medical/telemetry/oncology units; the acute locked

mental health unit; one CLC unit; and the intensive care

units. We also inspected the emergency department, the

same day surgery and post-anesthesia areas, the

cardiac catheterization suite, the oncology clinic, the

dialysis unit, and the offsite dental clinics. 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 that facilities using N95 respirators fit

test designated employees annually. We reviewed

33 employee records and determined that 21 (64 percent)

designated employees did not have the required annual fit

testing.

Environmental Safety. The Occupational Safety and Health

Administration and The JC require that facilities maintain

current MSDS inventory lists and hazardous material

information for chemicals used in clinical areas. We

reviewed 14 MSDS inventory lists and found that 5 were not

current and did not contain all required information.

9 VHA Handbook 1004.02. 

VA OIG Office of Healthcare Inspections 7
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

VA OIG Office of Healthcare Inspections 8

Recommendations 11. We recommended that N95 respirator fit testing be

completed annually for designated employees and that

compliance be monitored.

12. We recommended that processes be strengthened to

ensure that MSDS inventory lists and hazardous material

information are current and contain all required information.

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

15 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.

Medication

Management

The purpose of this review was to determine whether the

facility employed safe practices in the preparation, transport,

and administration of hazardous medications, specifically

chemotherapy, in accordance with applicable requirements.

We observed the compounding and transportation of

chemotherapy medications and the administration of those

medications in the oncology/chemotherapy clinic, and we

interviewed employees. We determined that the facility

safely prepared, transported, and administered the

medications. We made no recommendations.

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 22 C&P files and profiles and meeting minutes

during which discussions about the physicians took place.

We determined that the facility had implemented a consistent

C&P process that met current requirements. We made no

recommendations.
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

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

and recommendations and provided acceptable improvement plans. See

Appendixes D and E, pages 15–20, 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 9
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Appendix A

Facility Profile10

Type of Organization Tertiary care facility

Complexity Level 1b

VISN 16

Community Based Outpatient Clinics Columbus, MS

Greenville, MS

Hattiesburg, MS

Kosciusko, MS

McComb, MS

Meridian, MS

Natchez, MS

Veteran Population in Catchment Area 108,436

Type and Number of Total Operating Beds:

 Hospital, including Psychosocial

Residential Rehabilitation Treatment

Program

155 total (128 hospital, 27 residential)

 CLC/Nursing Home Care Unit 86

Medical School Affiliation(s) University of Mississippi

 Number of Residents 42.5

FY 2011 (through

March 2011)

Prior FY (2010)

Resources (in millions):

 Total Medical Care Budget $263 $215

 Medical Care Expenditures $173 $215

Total Medical Care Full-Time Employee

Equivalents

1,860 1,865

Workload:

 Number of Station Level Unique

Patients

38,631 44,715

 Inpatient Days of Care:

o Acute Care 15,802 31,561

o CLC/Nursing Home Care Unit 13,176 36,624

Hospital Discharges 2,667 5,391

Total Average Daily Census (including all bed

types)

86.8 86.5

Cumulative Occupancy Rate (in percent) 67.8 67.6

Outpatient Visits 230,425 456,282

10 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 10
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Appendix B

Follow-Up on Previous Recommendations

Recommendations Current Status of Corrective Actions

Taken

In Compliance

Y/N

Repeat

Recommendation?

Y/N

N

QM

1. Ensure that mechanisms are in place to

adequately evaluate and disclose adverse

events in accordance with VHA policy.

Facility consulted with VA Central

Office to clarify what is required and

now discloses all known complications.

Y

2. Fully document PRC discussions in

committee minutes.

Peer Review Coordinator implemented

changes to the structure of committee

minutes.

Y N

3. Complete peer reviews within the

required timelines.

Peer Review Coordinator tracks

reviews for timeliness and coordinates

with VISN as needed for timely

external reviews.

Y N

N

EOC

4. Secure medication room in the

post-anesthesia care unit.

Post-anesthesia care unit location

added to daily nursing supervisor

rounds.

Y

5. Clean air ventilation outlets in the CLC and

on Ward 4CS according to standard operating

procedures.

A schedule was developed for cleaning

air vents in all areas of the facility.

Y N

6. Maintain cleanliness of the dialysis unit. There is a regular daily schedule for

cleaning the unit.

Y N

N

Medication Management

7. Document effectiveness of as needed

medications.

Monitored monthly at Clinical

Informatics Committee. Recent audits

show 95–96 percent compliance.

Y

VA OIG Office of Healthcare Inspections 11
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Recommendations Current Status of Corrective Actions

Taken

In Compliance

Y/N

Repeat

Recommendation?

Y/N

Suicide Safety Plans

8. Comply with VHA regulations regarding

documentation of safety plans for patients

deemed at high risk for suicide.

Documentation of suicide prevention

safety plans occurs at hospital

discharge. Suicide Prevention

Coordinator tracks compliance on data

dashboard.

Y N

VA OIG Office of Healthcare Inspections 12
= =

CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

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 61.7 60.5 70.8 68.7 57.1 56.8 56.1 49.4

VISN 66.1 64.6 63.1 61.8 53.1 54.3 54.6 50.8

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 13
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

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

conditions11 received hospital care. The mortality (or death) rates focus on whether

patients died within 30 days of their hospitalization. The rates of readmission focus on

whether patients were hospitalized again within 30 days. Mortality rates and rates of

readmission show whether a hospital is doing its best to prevent complications, teach

patients at discharge, and ensure patients make a smooth transition to their home or

another setting. The hospital mortality rates and rates of readmission are based on

people who are 65 and older. These comparisons are “adjusted” to take into account

their age and how sick patients were before they were admitted to the VA facility.

Table 2 below shows the facility’s Hospital Outcome of Care Measures for

FYs 2006–2009.

Table 2

Mortality Readmission

Heart Attack Congestive

Heart

Failure

Pneumonia Heart Attack Congestive

Heart

Failure

Pneumonia

Facility 16.52 12.34 21.41 20.71 20.93 16.96

VHA 13.31 9.73 15.08 20.57 21.71 15.85

11 Congestive heart failure is a weakening of the heart’s pumping power. With heart failure, your body does not get 

enough oxygen and nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens 

when blood flow to a section of the heart muscle becomes blocked, and the blood supply is slowed or stopped. If 

the blood flow is not restored in a timely manner, the heart muscle becomes damaged from lack of oxygen. 

Pneumonia is a serious lung infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, 

and fatigue. 

VA OIG Office of Healthcare Inspections 14
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Appendix D

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: August 12, 2011

From: Director, South Central VA Health Care Network (10N16)

Subject: CAP Review of the G.V. (Sonny)

Medical Center, Jackson, MS

Montgomery VA

To: Director, Bay Pines Office of Healthcare Inspections (54SP)

Director, Management

Management Review)

Review Service (VHA 10A4A4

1.&I have reviewed the attached draft management report and concur with

the recommendations and actions.

2.&If you have any questions regarding the response, please contact

Mary Jones, HSS at 601-206-6974.

(original signed by:) 

GEORGE H. GRAY, JR.

Director, South Central VA Health Care Network (10N16)

VA OIG Office of Healthcare Inspections& 15
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

 Appendix E

Interim Facility Director Comments

Department of

Veterans Affairs Memorandum

Date:	 August 12, 2011

From:	 Interim Director, G.V. (Sonny) Montgomery VA Medical

Center (586/00)

Subject:	 CAP Review of the G.V. (Sonny) Montgomery VA

Medical Center, Jackson, MS

To:	 Director, South Central VA Health Care Network (10N16)

1.&Enclosed are the responses to the recommendations in the draft

report: Combined Assessment Program Review, G.V. Sonny

Montgomery VA Medical Center, Jackson, MS.

2.&If you have any questions or would like to discuss the report, please

contact me at (601) 364-1204.

(original signed by:) 

SHANNON NOVOTNY'

Acting Center Director, G. V. (Sonny) Montgomery VA Medical Center'

VA OIG Office of Healthcare Inspections& 16
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Comments to Office of Inspector General’s Report
 

The following Interim 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

all violent incidents involving employee victims are discussed at the ARB and that

compliance is monitored.

Target date for completion: September 1, 2011

Concur: The ARB will discuss all violent incidents involving employee victims entered

into the Automated Safety Incident Survelliance and Tracking System during quarterly

meetings. Safety Officer/Designee will ensure minutes capture discussion of each

Automated Safety Incident Survelliance and Tracking System incident.

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

the DBC’s decisions to place PRFs in the EMR are carried out and that compliance is

monitored.

Target date for completion: August 31, 2011

Concur: Upon determination that a Patient Record Flag (PRF) be placed, it will be

entered during the Disruptive Behavior Committee (DBC) meeting. In addition, the DBC

has developed a spreadsheet to track documentation of all elements of patient record

flag placement. Compliance will be monitored through the DBC minutes, and the

spreadsheet. The DBC policy will also be revised to state that during emergencies the

COS/designee may immediately approve PRF placements in the EMR.

Recommendation 3. We recommended that Police Service routinely share UORs for

incidents involving workplace violence with the DBC.

Target date for completion: August 3, 2011

Concur: The Police Chief/Designee is now submitting the Uniform Offense Report to

the Disruptive Behavior Committee monthly. The data is now captured and tracked in

DBC minutes and is a standing agenda item.

Recommendation 4. We recommended that facility policy identify actions to be taken

when RN competency does not meet expectations.

Target date for completion: August 31, 2011

Concur: The Competency Assessment Policy K-05-26 will be revised to include the

actions that will be taken when an individual does not meet competency expectations.

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CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

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

RN competency validation documentation is complete and that methods used to assess

and validate competency are specified.

Target date for completion: August 15, 2011

Concur: One hundred percent of the folders assessed during the RN Competency

Review that required actions were corrected by the appropriate Head Nurse and

reviewed by the Deputy Associate Director for Patient Care Services for 2A, SICU and

1st Floor CLC. Deputy Associate Director for Patient Care Services for units 2A, SICU,

and 1st Floor CLC will continue to monitor competency folders quarterly to ensure all

documentation is complete including validation methods and signatures.

Recommendation 6. We recommended that managers specify the qualifications

required for individuals who perform RN competency assessment and validation.

Target date for completion: August 31, 2011

Concur: The Competency Assessment Policy K-05-26 will be revised to include a

process for Managers/Supervisors to identify those who are competent to assess the

competency of others.

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

PRC minutes include documentation of completed corrective actions and that

compliance is monitored.

Target date for completion: July 1, 2011

Concur: The peer review process has been strengthened to ensure documentation of

corrective action completion is included in the Peer Review Committee minutes.

Recommendation 8. We recommended that processes be strengthened to ensure that

risk assessments are documented prior to procedures requiring moderate sedation and

that compliance is monitored.

Target date for completion: August 31, 2011

Concur: The facility policy has been revised to ensure that Anesthesiologists or

Certified Registered Nurse Anesthetists complete the risk assessment if it has not been

completed by the provider prior to initiating a procedure with moderate sedation. If the

procedure does not require an Anesthesiologist or Certified Registered Nurse

Anesthetist, the provider performing the procedure will be responsible for completing the

risk assessments. Compliance will be monitored quarterly by the Procedure Review

Committee.

VA OIG Office of Healthcare Inspections 18
CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Recommendation 9. We recommended that processes be strengthened to ensure that

all resuscitation events are reviewed and documented in CPR Committee meeting

minutes and that compliance is monitored.

Target date for completion: June 29, 2011

Concur: The CPR Committee minutes have been revised to reflect review of individual

resuscitation events. The Code spreadsheet is now embedded within the committee

minutes along with a summary of the resuscitation events.

Recommendation 10. We recommended that processes be strengthened to ensure

that all components of advance directive notification are documented, that advance

directive screening is accurately documented in the EMR, and that advance directives

completed on the VA form are appropriately witnessed.

Target date for completion: August 31, 2011

Concur: The Advance Directive notification process was strengthened to reflect the

current VHA Directive. The facility made changes to the advance directive progress

note templates in the electronic medical record during the survey to include all

components required for written documentation of advance directive notification.

Providers were educated on this change on June 17, 2011. A Systems Redesign Team

is revising the facility Advance Care Planning policy to delineate all components of

documentation required during advance directive notification. Training programs are

currently being developed for each discipline involved in the advance care planning

process. The updated policy will emphasize the requirement for two witnesses when

advance directives are executed.

Recommendation 11. We recommended that N95 respirator fit testing be completed

annually for designated employees and that compliance be monitored.

Target date for completion: August 1, 2011

Concur: FMS has developed a spreadsheet for tracking the N95 Fit Testing program.

Services are now required to compile a list of employees for testing and referral to

Employee Health for a screening prior to fit testing. The employee’s Service will then

contact FMS to schedule fit testing. FMS will maintain the facility spreadsheet and

notify services when annual N95 Fit Testing is due.

Recommendation 12. We recommended that processes be strengthened to ensure

that MSDS inventory lists and hazardous material information are current and contain all

required information.

Target date for completion: August 31, 2011

Concur: FMS has created a spreadsheet to track and monitor updates of MSDS

annually.

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CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

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 Christa Sisterhen, MCD, Project Leader

Karen McGoff-Yost, MSW, LCSW, Team Leader

Darlene Conde-Nadeau, MSN, ARNP

David Griffith, RN, FAIHQ

Alice Morales-Rullan, MSN, CNS

Carol Torczon, MSN, ACNP

John Ramsey, Resident Agent in Charge, Office of Investigations

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CAP Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Appendix G

Report Distribution

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, South Central VA Health Care Network (10N16)

Interim Director, G.V. (Sonny) Montgomery VA Medical Center (586/00)

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: Thad Cochran, Roger F. Wicker

U.S. House of Representatives: Gregg Harper, Bennie G. Thompson

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

VA OIG Office of Healthcare Inspections 21