Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Alleged Quality of Care Issues
 

Captain James A. Lovell
 

Federal Health Care Center,
 

North Chicago, Illinois
 

Report No. 11-00768-292 September 29, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of multiple allegations regarding the quality of care 

in the mental health clinic and two medical specialty clinics at Captain James A. Lovell 

Federal Health Care Center (the medical center), Chicago, IL. 

We substantiated the allegation that two mental health providers issued narcotics on 

2 days leading up to the patient’s death. We did not substantiate the allegation that 

narcotics were given outside the narcotic agreement; the agreement addressed patient 

behaviors, not a specific narcotic regimen. 

We determined that the patient received additional prescriptions for hydrocodone before 

his prior prescriptions had elapsed. We found that pill counts to assess the patient’s 

medication compliance were not documented; therefore, we were unable to determine if 

pills counts were done for this patient. While the choice of fentanyl patches was reached 

after extended discussion between the patient and physician, we had concerns with the 

prescription; fentanyl is a potent, long-acting agent and the patient’s fentanyl prescription 

was a substantial increase in his opioids. We believe that other possible options, 

including hospitalization or shorter prescriptions, would have allowed closer monitoring 

of the patient while adjusting his medications. 

We substantiated the allegation that urine drug screens were not performed. We 

substantiated the complainant’s allegation that medical center staff were aware of the 

positive drug screens done at Hines VA 2 weeks prior to the patient’s death. 

While we did not substantiate the allegation that the patient’s death was not properly 

reported and investigated, we found that the peer reviewer of the case was not certified in 

pain management. We believe that a specialist in pain management should review this 

case due to the nature of the incident. 

We determined that a contract physician specialist received fee basis referrals; however, 

we did not substantiate that the physician self-referred. We did find that the contract 

physician was the only available option listed in the fee basis consult package for service. 

The medical center added two additional fee basis physician specialists while we were 

on-site. 

We recommended that the Medical Center Director ensure that (1) patients with narcotic 

agreements are appropriately monitored for compliance with prescription medications 

and (2) a physician certified in pain management review this case. 

The VISN and Medical Center Directors agreed with our findings and recommendations. 

The implementation plans are acceptable, and we will follow up on the planned actions 

until they are completed. 

VA Office of Inspector General i 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, VA Great Lakes Health Care System (10N12) 

SUBJECT:	 Healthcare Inspection – Quality of Care Issues, Captain James A. Lovell 

Federal Health Care Center, Chicago, IL 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections received 

multiple allegations regarding the quality of care in the mental health (MH), oncology, 

and dermatology clinics at Captain James A. Lovell Federal Health Care Center 

(the medical center), Chicago, IL. The purpose of the review was to determine whether 

the allegations had merit. 

Background 

The medical center is a tertiary care hospital that is part of the Veterans Integrated 

Service Network (VISN) 12. The medical center provides a broad range of outpatient 

services including MH. The Mental Health Clinic provides outpatient services Monday 

through Friday from 8:00 a.m. to 5:00 p.m. In fiscal year (FY) 2011, 26,382 unique 

patients were seen in the clinic. 

On February 1, 2011, an anonymous complainant contacted the OIG hotline and alleged 

that: 

	 Two MH providers issued narcotics outside the narcotic agreement on 2 days 

leading up to the patient’s death. 

	 The patient did not have urine drug screens completed prior to being prescribed 

narcotics. 

	 MH staff was aware of the drug screen performed at Hines VA 2 weeks prior to 

the patient’s death, which showed multiple high levels of illegal substances in his 

system. 

	 Email messages sent to the Director of Mental Health 1 day prior to the patient’s 

death and to the Medical Center Director the day after his death warned of narcotic 

issuing and its relation to the patient’s death. 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

	 The patient’s death was not properly reported and investigated. 

	 A physician in a medical specialty clinic took multiple weeks of annual leave 

without making provisions to ensure patient care needs were met. 

	 Management was aware that a physician was on vacation for 5 weeks and 

approximately 100 patients did not receive care. 

	 A contract physician self-referred patients for fee basis1 service. 

There were other allegations regarding administrative issues, which were referred 

elsewhere for review. 

Scope and Methodology 

We conducted a site visit on April 12–13, 2010. We interviewed the Chief of Staff, 

Chief, Ambulatory Care, quality manager, neurologist, psychiatrists, Emergency 

Department (ED) physicians, clinical pharmacist, nursing staff, and a clinic scheduling 

clerk. We reviewed the patient’s medical records and pertinent medical center and 

Veterans Health Administration (VHA) policies and procedures. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

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

Efficiency. 

Case Summary 

The patient was a male with a psychiatric history that includes bipolar, depression, 

anxiety, and personality disorders. He had a long history of substance abuse, primarily 

cocaine and alcohol dependence with numerous hospital admissions for treatment of 

substance abuse and psychiatric disorders. His medical history includes chronic low back 

pain secondary to degenerative disk disease. 

In mid-November, 2009, the patient signed a patient treatment contract and a narcotic 

agreement. The conditions of the treatment contract were: 

	 14 day prescriptions with no refills. 

	 No early refills. 

	 ED visit for acute new onset issues. 

1 Fee basis referral is an authorization to receive care in the community by a non VA provider. 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

 Compliance with all aspects of the narcotic agreement including random urine 

drug screens. 

The narcotic2 (opiate) agreement described specific behaviors the patient was to adhere to 

while receiving opiate treatment and did not stipulate a specific medication regimen. The 

following were the conditions of the agreement: 

 Receive treatment for persistent pain from only one health care provider and 

discuss all aspects of pain including how well the medicine is relieving pain. 

 Receive a comprehensive pain assessment and treatment plan. 

 Avoid the use of any illegal substances, including marijuana, cocaine, and heroin. 

 Avoid sharing, selling or trading medications with anyone. 

 Protect medication from loss or theft. 

 Refill pain medicine during clinic hours. 

 Take medicine as prescribed by health care provider. 

 Contact health care provider if pain is poorly controlled. 

 Bring unused pain medicine and prescription vials for pill counts to each office 

visit. 

 Submit to random blood and/or urine testing. 

 Keep all scheduled appointments. 

At that time, the patient was prescribed hydrocodone3 5 milligram (mg)/acetaminophen 

500 mg 1 tablet every 6 hours as needed for pain. The patient’s urine screen was positive 

for opiates and benzodiazepines (class of drugs used for treating anxiety) and negative for 

cocaine. 

One month later, a neurologist was consulted to assess the patient for 

non-pharmacologic pain treatment. The neurologist noted that the patient had no clinical 

signs or symptoms of spinal nerve root irritation. The neurologist did a trigger point 

2 Narcotic is an addictive drug, such as opium, that reduces pain, alters mood and behavior, and usually induces
 

sleep or stupor.

3 Hydrocodone is a synthetic opioid analgesic similar to but more active than codeine.
 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

injection and noted that the patient responded well. The neurologist ordered a 

transcutaneous electrical nerve stimulation unit4

. 

One week later, the patient presented to the ED with complaints of back pain. He rated 

the intensity of his pain at 7 out of 10.5 He reported that his medications were stolen and 

presented a police report. He received hydromorphone6 1 mg intramuscular (IM) for pain 

and lorazepam (relieve anxiety) 1 mg IM. The patient received a prescription for 

hydrocodone 10 mg/acetaminophen 650 mg 1 tablet 3 times a day as needed for pain. He 

was issued a 5 day supply and referred back to his MH primary care physician (PCP) for 

follow up. The patient saw his MH PCP 4 days later. The MH PCP noted “patient 

continues to exhibit inconsistent behavior necessitating weekly visits and medication 

refills.” 

In early January 2010, the patient presented to the ED with complaints of back pain. He 

rated the intensity of his pain at 8. The ED physician wrote, “patient hostile, verbally 

abusive, and demanded narcotics.” The physician consulted a neurologist who 

recommended a nonsteroidal anti-inflammatory drug, skelaxin (muscle relaxant) and 

referral to a pain clinic. The patient was given hydromorphone 1 mg IM for acute pain 

and referred back to MH PCP for follow up. 

Three days later, the MH PCP wrote “patient continued to engage in negative behaviors 

as evidenced by visiting Hines VA. Patient stated that he lost his valium and Vicodin® 

[hydrocodone] while at his families’ home. He visited the ED at the medical center 

without a medical rationale for worsened pain. He was hostile and abusive to providers.” 

The MH PCP noted that the patient was noncompliant with the narcotic agreement and in 

early February, the patient met with a new MH PCP. At that time, the new provider 

prescribed hydrocodone 10 mg/acetaminophen 650 mg 1 tablet 3 times a day as needed 

for pain. Twenty-four days later, the patient accessed the ED again for complaint of back 

pain and received hydromorphone 2 mg IM. 

In mid-March, the MH PCP wrote that the undersigned would coordinate all medical 

care. The patient was advised to keep scheduled appointments or medications would not 

be prescribed, nor would he receive any early refills. The patient was seen in the ED 

once in March but was referred back to his MH PCP for changes in pain management. 

The patient received a fee basis referral to a non-VA pain clinic and was seen in late 

March. The patient received a transforaminal epidural steroid injection.7 He was to 

4 Transcutaneous electrical nerve stimulation unit modify the perception of pain through the release of endorphins as
 

well as alterations in nerve sensitivity.

5 Intensity of pain ranges from 0-10 with 10 as most severe.
 6 Hydromorphone is a synthetic derivative of morphine used as a respiratory sedative and analgesic that is more
 

potent than morphine.

7 Transoraminal epidural injections are commonly given to patients with nerve compression or irritation to relieve
 

pain.
 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

return in 7 to 10 days for re-evaluation; however, there was no documentation of a follow 

up visit. 

One day later, the patient was admitted to the inpatient MH unit for drug seeking 

behavior and depression. His drug screen was positive for cocaine. The patient wanted 

to leave on hospital day (HD) 2 due to the restrictive nature of the inpatient environment. 

The patient signed out against medical advice on HD 3. The physician noted that he was 

not suicidal or homicidal. 

Twenty-five days later, the patient had positive drug screens for cocaine and was 

admitted to the inpatient substance abuse treatment program for withdrawal from cocaine 

and heroin. He attended the physical fitness program and group therapy. He participated 

in Alcoholics Anonymous 12-step educational group, recreational therapy, dietician's 

educational group, and other psychoeducational groups. The patient was discharged on 

HD 23. 

For a 21 day period starting from 8 days post-discharge, the patient was seen in the ED 

six times requesting narcotics for complaints of back pain and received narcotic 

injections IM. Random urine drug screens were negative for cocaine. 

The clinical pharmacist noted that the patient had tried multiple different medications in 

the past for pain including acetaminophen, aspirin, naproxen, ibuprofen, diclofenac, 

celecoxib, indomethacin, carisoprodol, cyclobenzaprine, metaxalone, tramadol, 

hydrocodone, and lidocaine patches. The patient reported that most of these medications 

had offered him no relief and that only the hydrocodone was helpful. He was willing to 

sign another narcotic agreement if it was necessary to continue his current treatment. The 

pharmacist noted that the patient admitted to an addictive personality and understood the 

risks of using opiates. 

Thirty-four days post-discharge, the patient signed a second narcotic agreement with the 

new MH provider, which contained the same conditions as the first agreement. The MH 

PCP prescribed fentanyl patch 12.5 mcg every 3 days; however, the medication was not 

in stock in the pharmacy. The MH PCP instructed the patient to continue hydrocodone 

10 mg 3 times a day for 2 days until the fentanyl patch was available. He was to follow 

up with psychiatry every 2 weeks. Due to increased complaints of pain, the MH PCP 

increased the dosage of the fentanyl patch to 25 mcg 10 days later. 

Five days later, a urine drug screen was positive for benzodiazepine and negative for 

opiates and cocaine. There were no other urine drug screens ordered. The patient 

accessed the ED once in August and again in September seeking narcotics to treat his 

back pain. He received hydromorphone 2 mg IM at both visits. 

In early September, the patient was admitted to the Milwaukee VA for detoxification 

from opiates and benzodiazepine. The physician noted that the patient reported 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

frustration with pain control and did not feel the current fentanyl patch was effective in 

controlling his pain; thus, he relapsed to cocaine, using large amounts. The physician 

requested outpatient consults for neurosurgery and an electromyogram.8 The patient was 

discharged on HD 3. He had an appointment for the electromyogram 11 days later; 

however, he did not present for his appointment. 

In early October, the patient’s family took him to the Hines VA for concerns about 

suicidal ideation and escalating drug use. His urine drug screen was positive for cocaine, 

marijuana, barbiturates, and opiates. His blood alcohol level was also high. The patient 

was admitted to the Jesse Brown VA inpatient psychiatric unit for treatment of 

depression and polysubstance abuse. The patient left treatment abruptly 4 days later. 

The psychiatrist recommended further treatment, but noted the patient was not suicidal 

and was able to articulate the discharge plan. The patient was deemed safe for discharge 

at that time. The physician prescribed hydrocodone 5 mg/acetaminophen 500 mg 2 

tablets every 6 hours as needed for pain. The patient was given a 2 week supply with one 

refill. He was advised to abstain from drinking and drugs and to follow through with his 

plan to start rehabilitation. 

Nine days later, the patient presented to the medical center’s Mental Health Clinic. A 

psychiatrist saw the patient and documented that he was alert, oriented, pleasant, and 

cooperative. His mood was stable, insight was poor, and judgment was intact. The 

psychiatrist noted that the urine drug screens from the Hines VA were positive. The 

patient wanted his pain medication changed to something other than hydrocodone; 

however, he was given a prescription refill for 1 week of hydrocodone 

10 mg/acetaminophen 650 mg 1 tablet 3 times a day. 

The next day, the patient presented to the ED requesting temporary pain management. He 

reported not having any medication and his pain was not being managed. The patient 

rated the intensity of his pain at 8 and was given hydromprphone 2 mg IM. 

Later that day, the patient met with the MH treatment team (MH PCP, MH attending 

physician, clinical pharmacy specialist, nurse, and the MH program manager). The 

patient reported hydrocodone did not relieve his pain. He requested oxycontin9

, which 

was declined. The MH PCP noted that the team expressed concerns about his use of 

cocaine, alcohol, and barbiturates and the danger of mixing these substances with 

narcotics. The patient stated that he had been tolerating these medications for a while. 

He acknowledged that he had been "buying stuff from the streets" and blamed 

"inadequate pain control for his use of cocaine and alcohol.” The MH PCP noted that the 

patient rejected methadone treatment, but reluctantly agreed to the fentanyl patch. The 

patient was informed that he would be checked for toxicology and the need for evaluation 

by pain clinic providers at Jesse Brown was discussed. The meeting ended with an 

8 Electromyogram is an electrical recording of muscle activity that aids in the diagnosis of neuromuscular disease. 

9 Oxycontin is a potent narcotic pain reliever with high abuse potential. 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

agreement for the patient to receive fentanyl patch 37.5 microgram (mcg) and referral to 

a pain clinic. He was advised to use “2–3 Vicodin® [hydrocodone] for breakthrough 

pain.” 

The patient received fentanyl patch 50 mcg due to the unavailability of the fentanyl patch 

37.5 mcg in pharmacy. The MH PCP instructed the patient not to use “any illicit 

substances, any alcohol, and any additional opiates for breakthrough pain or recreational 

purposes.” 

The next day, the patient died from an accidental overdose. The toxicology screen was 

positive for cocaine, fentanyl, and hydrocodone. 

Inspection Results 

Issue 1: Mental Health Chronic Pain Management 

We substantiated the allegations that two MH providers issued narcotics 2 days leading 

up to the patient’s death; however, we did not substantiate the complainant’s allegation 

that the MH providers issued narcotics outside the narcotic agreement. We substantiated 

the allegation that the patient did not have random drug screens and that the staff was 

aware of the drug screen performed at Hines VA 2 weeks prior to the patient’s death. We 

could neither substantiate nor refute the allegation that email messages sent to the 

Medical Center Director and Director of Mental Health warned of narcotic issuing and its 

relation to the patient’s death. We did not substantiate the allegation that the medical 

center did not properly report and investigate the patient’s death. 

Narcotic Prescriptions. We reviewed the medical record and found that opiate treatment 

was warranted for this patient due to failure of less potent pain management options. We 

also found that the patient was a known substance abuser and attributed his use of illicit 

drugs to poor pain management. We substantiated the complainant’s allegation that the 

patient received two prescriptions for narcotics prior to his death. We found that on 2 

days in October, the patient received new narcotic prescriptions while he would have 

been expected to have significant quantities of his prior prescriptions. We determined 

that the patient’s last narcotic prescription was for a potent, long-acting medication at a 

larger dose. In addition, we found that pill counts were not documented; therefore, we 

were unable to determine if the pill counts for this patient were done. We reviewed the 

narcotic agreement which specified pill counts would be completed at each clinic visit to 

assess compliance with prescriptions. We did not validate the allegation that narcotics 

were given outside the narcotic agreement. The agreement addressed patient behaviors, 

not a specific narcotic regimen. 

We also found that from December, 2009 to October, 2010, the patient accessed the ED 

14 times seeking narcotics for complaints of back pain. He received a narcotic injection 

IM during 12 of the 14 visits. The ED providers were aware that the patient was on a 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

narcotic agreement. Medical center leadership acknowledged the need for a pain 

management specialist and reported that a request to hire an anesthesiologist to start a 

pain management program was recently approved. 

Urine Drug Screens. We reviewed the medical record and found that random urine drug 

screens were not ordered after June 2010. The veteran had 24 urine drug screens in the 

first half of 2010, and none at the medical center in the second half of the year. Urine 

drug screens are an important part of monitoring adherence with prescriptions and 

identifying the use of illicit substances. We validated the complainant’s allegation that 

staff at the medical center was aware of the results of the positive urine drug screens done 

at Hines VA. 

Email Messages. Only a subset of emails from the Medical Center Director and the 

Director of Mental Health could be reviewed. We searched the available email of the 

Medical Center Director and the Director of Mental Health and found no messages 

warning of narcotics prescribed for this patient. 

Death Investigation. We found that the medical center did a peer review10 of the 

incident; however, the peer reviewer was not certified in pain management. We also 

found that the incident was reported according to local policy. 

Issue 2: Medical Clinic Physician Coverage 

We did not substantiate the allegation that the physician in a medical clinic took multiple 

weeks of annual leave without properly handling patient care needs. We also did not 

substantiate the allegation that management was aware that approximately 

100 patients did not receive care during the 5 weeks the physician was on vacation. 

We reviewed the physician’s official time and leave record for FY 2010 and found that 

the physician was on leave for 3 consecutive weeks in July. We found that the 

physician’s leave was scheduled months in advance and provisions were made for 

patients to be seen through fee basis referrals including all new consultations. We 

reviewed six fee basis referrals initiated in July 2010 during the time the physician was 

on leave. We also reviewed the clinic’s patient advocate reports for FY 2010, and there 

were no issues related to access to care or the quality of care of patients assigned to this 

provider. 

Issue 3: Medical Clinic Contract Physician 

We did not substantiate the allegation that a contract physician was self-referring 

patients. We determined that the physician received fee basis referrals for all initial 

consultations. However, our review of 50 consultations for this service revealed that the 

10 Peer review is an organized process carried out by an individual health care professional or select committee of 

professionals, to evaluate the performance of other professionals. 

8 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

contract physician was not the requestor on any of the consults. We found that the nurse 

in the clinic reviewed the consults and generated a fee basis referral for all initial 

consultations. The nurse also notified the patients and instructed them to call the contract 

physician’s private office to make an appointment. 

Medical center leaders reported that the number of patients that required this specialty’s 

services exceeded the available clinic hours, and they were unsuccessful in recruiting a 

full time physician. In addition, we were told that efforts had been made in the past to 

locate physicians to provide this service in the community; however, none were willing to 

accept VA patients on a fee for service basis. 

VHA requires that patients who are authorized short-term fee basis treatment may select 

a qualified physician of their choice to render the services required. In the absence of this 

selection, VHA requires that medical administration personnel arrange for treatment by a 

qualified physician located within a reasonable distance of the patient’s residence. We 

determined that the contract physician was the only physician listed on the electronic fee 

basis outpatient consult as an option to provide this fee basis service. While we were onsite, medical center leaders added two additional fee basis physicians to provide this 

service. 

Conclusions 

We substantiated the allegation that two MH providers issued narcotics on 2 days leading 

up to the patient’s death. We believe that the patient’s treatment team did many things 

well with the management of his care including extensive consultation for non 

pharmacologic approaches to pain management. The treatment team regularly followed 

the patient and had a narcotic agreement in place with him. However, the facility did not 

have a pain management consultant available to advise the patient’s mental health 

providers. The patient received additional prescriptions for hydrocodone before his prior 

prescriptions had elapsed without pills counts to determine his medication compliance. 

While the choice of fentanyl patches for control of pain was reached after extended 

discussion between the patient and physician, we had concerns with the prescription; 

fentanyl is a potent, long-acting agent and the patient’s fentanyl prescription was a 

substantial increase in his opioids. We believe that other possible options including 

hospitalization or shorter prescriptions would have allowed closer monitoring of the 

patient while adjusting his medications. 

We do not believe that the ED provider’s actions were inappropriate. The patient was 

given an injection of short-acting narcotics and referred back to the MH PCP for chronic 

pain management. 

We substantiated the allegation that urine drug screens were not performed. We 

substantiated the complainant’s allegation that the medical center staff were aware of the 

drug screens done at Hines VA, which were positive for illegal substances. Although we 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

did not substantiate the allegation that the patient’s death was not properly reported and 

investigated, we found that the peer reviewer was not certified in pain management. We 

believe that a specialist in pain management should review this case due to the nature of 

the incident. 

We could neither substantiate nor refute the allegation involving email messages warning 

of the narcotics prescribed for this patient. 

We determined that a contract physician received fee basis referrals; however, we did not 

substantiate that the physician self-referred. We did find that the contract physician was 

the only available option listed in the fee basis consult package for services. The medical 

center added two additional fee basis physicians while we were on-site. 

We did not substantiate the other allegations related to MH providers issuing narcotics 

outside the narcotic agreement, or the physician in a medical clinic taking multiple weeks 

of annual leave and that managers were aware that multiple patients did not receive care 

during that time. 

Recommendations 

Recommendation 1. We recommended that the Medical Center Director ensure that 

patients with narcotic agreements are appropriately monitored for compliance with these 

agreements. 

Recommendation 2. We recommended that the Medical Center Director ensure that a 

physician certified in pain management review this case. 

Comments 

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

The implementation plans area acceptable, and we will follow up on the planned actions 

until they are completed. 

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

Assistant Inspector General for 

Healthcare Inspections 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 August 2, 2011 

From:	 Director, VA Great Lakes Health Care System (10N12) 

Subject:	 Healthcare Inspection – Alleged Quality of Care Issues at 

Captain James A. Lovell Health Care Center, North Chicago, 

Illinois 

To:	 Director, San Diego Office of Healthcare Inspections (54SD) 

Thru:	 Director, Management Review Service (10B5) 

Attached please find the Lovell FHCC response to the alleged 

quality of care issues. I have reviewed and concur with the 

response. 

(original signed by:) 

Jeffrey Murawsky
 

Director, VA Great Lakes Health Care System (10N12)
 

VA Office of Inspector General 11 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 August 2, 2011 

From:	 Director, Captain James A. Lovell Federal Health Care 

Center (556/00) 

Subject:	 Healthcare Inspection – Alleged Quality of Care Issues at 

Captain James A. Lovell Health Care Center, North Chicago, 

Illinois 

To:	 Director, VA Great Lakes Health Care System (10N12) 

This is to acknowledge receipt and review of the 

recommendation of the Office of the Inspector General. 

Attached is our response and request for closure. 

(original signed by:) 

Patrick Sullivan 

Director, Captain James A. Lovell Federal Health Care 

Center (556/00) 

VA Office of Inspector General 12 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

Director’s Comments
 

to Office of Inspector General’s Report
 

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

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the Medical Center Director 

ensure that patients with narcotic agreements are appropriately monitored 

for compliance with prescription medications. 

Concur: Target Completion Date: October 1, 2011 

Facility’s Response: 

JAL FHCC will comply with the current requirement of the Narcotic 

Agreement, which includes random blood and /or urine testing. The 

Narcotic Agreement will be modified to also include random pill counts. 

Education of providers regarding Narcotic Agreements will be completed 

by September 30, 2011. A random sample of 10 percent of records of 

patients with narcotic agreements will then be monitored monthly for 

6 months to validate compliance. 

Status: In process. 

Recommendation 2. We recommended that the Medical Center Director 

ensure that a physician certified in pain management review this case. 

Concur: Target Completion Date: October 1, 2011 

Facility’s Response: 

The case was reviewed by a physician certified in pain management on 

August 1, 2011. 

Status: Completed. 

VA Office of Inspector General 13 
Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

Appendix C 

OIG Contact and Staff Acknowledgments 

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

Office of Inspector General at (202) 461-4720 

Acknowledgments Deborah Howard, RN, Project Leader 

Judy Montano, MS 

Robert Yang, MD 

Derrick Hudson, Program Support Assistant 

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Alleged Quality of Care Issues, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Health Care System (10N12) 

Director, Captain James A. Lovell Federal Health Care Center (556/00) 

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: Richard J. Durbin and Mark Kirk 

U.S. House of Representatives: Robert J. Dold 

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

15