Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01106-207 

Combined Assessment Program
 

Review of the
 

VA Northern California
 

Health Care System
 

Sacramento, California
 

June 30, 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 Northern California Health Care System, Sacramento, CA 

Glossary 

BSC biological safety cabinet 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CHF congestive heart failure 

CLC community living center 

CS controlled substances 

ED emergency department 

EN enteral nutrition 

EOC environment of care 

facility VA Northern California Health Care System 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

IC infection control 

MEC Medical Executive Committee 

OIG Office of Inspector General 

QM quality management 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

Physician C&P................................................................................................... 3
 

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

EN Safety .......................................................................................................... 4
 

Medication Management ................................................................................... 5
 

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

Coordination of Care ......................................................................................... 5
 

Management of Workplace Violence................................................................. 6
 

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

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

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

Appendixes 

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

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 10
 

D. VISN Director Comments .................................................................................. 12
 

E. Facility Director Comments ............................................................................... 13
 

F. OIG Contact and Staff Acknowledgments ......................................................... 17
 

G. Report Distribution ............................................................................................ 18
 

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

Review of the VA Northern California Health Care System,
 

Sacramento, CA
 

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 

April 11, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

 Coordination of Care 

 Management of Workplace Violence 

 Quality Management 

 Registered Nurse Competencies 

The facility’s reported accomplishments 

were the implementation of innovative 

patient transition of care strategies and 

an automated mammography tracking 

and reporting program. 

Recommendations: We made 

recommendations in the following four 

activities: 

Physician Credentialing and Privileging: 

Clearly document timeframes on 

physicians’ Focused Professional 

Practice Evaluation forms, and report 

results to the Medical Executive 

Committee. Document discussion of 

performance data for all physicians in 

Medical Executive Committee meeting 

minutes at the time of reprivileging. 

Environment of Care: Complete N95 

respirator fit testing annually, and 

monitor compliance. Ensure all laser 

users complete laser safety training, and 

monitor compliance. 

Enteral Nutrition Safety: Revise facility 

infection control policy to include enteral 

nutrition infection control expectations. 

Medication Management: Require that 

staff observe safe work practices when 

handling hazardous drugs. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

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 February 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 Northern California 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Health Care System, Sacramento, California, Report 

No. 08-01745-201, September 11, 2008). The facility had 

corrected all findings. (See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 276 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
 Patient Transition 

of Care Strategies 

Automated 

Mammography 

Tracking and 

Reporting Program 

The facility implemented innovative and systems-oriented 

strategies to facilitate patients’ transition from acute inpatient 

care to other levels of care. Transitions include when 

patients are discharged home or into a long-term care 

setting. CLC transition strategies included early admissions 

and increased referrals to home telehealth. In 2009, for CLC 

patients, the facility decreased its length of stay by 143 bed 

days of care and its readmission rates by more than 

75 percent. In 2010, for inpatients with CHF who 

transitioned to outpatient settings, the facility decreased its 

30-day readmission rates by 25 percent and its 30-day ED 

visits by 15 percent.1 These strategies have reduced 

hospital readmissions and ED delays and have improved 

overall patient care. 

The facility enhanced its services for women veterans by 

implementing an automated mammography tracking and 

reporting computer software program that is interfaced with 

the facility’s computer system. The program provides a 

repository of mammogram information for managing patient 

assessment profiles, viewing and editing mammography 

reports, and coordinating follow-up appointments. It has 

eliminated manual record keeping and provides accurate, 

paperless statistical tracking of mammography results. 

1 CHF 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. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Results 

Review Activities With 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 15 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following areas that needed improvement. 

FPPE. VHA requires that FPPE be time-limited and that 

results be reported to the MEC for consideration in making 

the recommendation on privileges for newly hired 

physicians.2 We reviewed the profiles of five newly hired 

physicians. Two of the profiles did not have a timeframe 

clearly documented on the FPPE form. In addition, no profile 

results were reported to the MEC. 

Ongoing Professional Practice Evaluation. VHA requires 

that at the time of reprivileging, service-specific performance 

data be collected and presented to the MEC for review and 

approval.3 We found that MEC meeting minutes did not 

include discussion of performance data for any of the 

10 applicable physician profiles reviewed. 

Recommendations	 1. We recommended that timeframes be clearly 

documented on physicians’ FPPE forms and that FPPE 

results be reported to the MEC. 

2. We recommended that at the time of reprivileging, MEC 

meeting minutes document discussion of performance data 

for all physicians. 

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. 

At the Sacramento division, we inspected 

selected inpatient (intensive care, telemetry, mental 

health, and medical-surgical) units, the same day 

surgery/post-anesthesia care unit, the ED, primary care and 

mental health clinics, and the infusion clinic. At the Martinez 

division, we inspected the CLC units, the same day 

2 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 3 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Recommendations 

EN Safety 

Recommendation 

surgery/post-anesthesia care unit, primary care clinics, and 

the urgent care clinic. The facility maintained a generally 

clean and safe environment. However, we identified the 

following conditions that needed improvement. 

N95 Respirator Fit Testing. If facilities use N95 respirators, 

the Occupational Safety and Health Administration requires 

that designated employees are fit tested annually. We 

reviewed 42 employee training records and determined that 

34 (81 percent) designated employees did not have the 

required annual fit testing. 

Laser Safety Training. Local policy requires that all laser 

users be trained on the proper use of such equipment. We 

reviewed 10 employee training records and found that 5 of 

the records did not have this training documented for 

FY 2010. 

3. We recommended that annual N95 respirator fit testing 

be completed and that compliance be monitored. 

4. We recommended that all laser users complete laser 

safety training and that compliance be monitored. 

The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. We also inspected areas where 

EN products were stored while conducting the EOC review, 

and we interviewed key employees. We identified the 

following area that needed improvement. 

EN IC Policy. VHA requires that facility IC policy address 

EN.4 We reviewed facility IC policy and determined that it 

did not address IC expectations for EN, such as swabbing 

the tops of EN cans with alcohol wipes before pouring 

contents into feeding bags. 

5. We recommended that facility IC policy be revised to 

include EN IC expectations. 

4 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Medication 

Management 

Recommendation 

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 infusion clinics at the 

Sacramento and Martinez divisions, and we interviewed 

employees. We identified the following area that needed 

improvement. 

Safe Work Practices. The American Society of 

Health-System Pharmacists requires safe handling of 

hazardous drugs to minimize contamination and ensure staff 

and patient safety. All items needed for compounding drugs 

must be gathered before beginning work, which should 

eliminate the need to exit the BSC once compounding has 

begun. However, if it is necessary to exit and re-enter the 

BSC, contaminated outer gloves must be removed before 

touching supplies, and new outer gloves must be donned 

before re-entering the BSC. In addition, transport bags must 

not be placed on contaminated surfaces in the BSC, and 

clean inner gloves must be worn when labeling and placing 

the final preparation into the transport bag. 

At the Martinez division, we observed a pharmacy staff 

member exit the BSC to gather additional supplies and 

re-enter without changing outer gloves. This staff member 

also inappropriately placed transport bags onto a 

contaminated work surface in the BSC. While we were 

onsite, managers began to take corrective actions by training 

staff and observing work practices to ensure adherence to 

safety procedures. 

6. We recommended that safe work practices be observed 

when handling hazardous drugs. 

Review Activities Without Recommendations
 

Coordination of 

Care 

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 and the facility’s 

advance care planning policy and determined that the facility 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

generally met VHA requirements. We made no 

recommendations. 

Management of	 The purpose of this review was to evaluate whether the 

Workplace facility issued and complied with comprehensive policy 

regarding violent incidents and provided required training. Violence 

We reviewed the facility’s policy and training plan. 

Additionally, we selected three assaults that occurred at the 

facility within the past 2 years, discussed them with 

managers, and reviewed applicable documents. The facility 

had a comprehensive workplace violence policy and 

managed the assaults in accordance with policy. The 

training plan addressed the required prevention and 

management of disruptive behavior training. We made no 

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. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

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

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies, interviewed nurse managers, 

and reviewed initial and ongoing competency assessment 

and validation documents for RNs. We determined that the 

facility had established an effective process to assess and 

validate RN competencies and that a plan was in place to 

take action if deficiencies were identified. We made no 

recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 12–16 for full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Appendix A 

Facility Profile5 

Type of Organization VA medical center 

Complexity Level 1c 

VISN 21 

Community Based Outpatient Clinics Martinez, CA 

Oakland, CA (2 clinics) 

Mare Island, CA 

Fairfield, CA 

McClellan, CA 

Redding, CA 

Chico, CA 

Yuba City, CA 

Yreka, CA 

Sacramento, CA (on facility campus) 

Veteran Population in Catchment Area 287,064 (94,618 enrollees) 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

60 

 CLC/Nursing Home Care Unit 115 

 Other None 

Medical School Affiliation(s) University of California, Davis 

 Number of Residents 389 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

December 2010) 

$513.4 

Prior FY (2010) 

$508.2 

 Medical Care Expenditures $126.7 $498.5 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

2,306 

51,262 

3,967 

2,289 

80,977 

16,506 

o CLC/Nursing Home Care Unit 10,066 38,894 

Hospital Discharges 1,307 5,142 

Total Average Daily Census (including all bed 

types) 

156.6 156.1 

Cumulative Occupancy Rate (in percent) 80 80 

Outpatient Visits 190,462 781,650 

5 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

QM 

1. Assure consistent data gathering, 

analysis, and reporting; document 

discussions about data analyses; and 

implement and evaluate actions to address 

problems or trends. 

We developed executive summaries 

for reporting committee activities. 

Mechanisms, such as dashboards and 

reporting calendars, were developed 

and implemented. Minute taking and 

performance improvement data 

training were provided to staff. 

Y N 

2. Initiate and maintain a process for 

comprehensive monitoring of medication 

reconciliation. 

Medication reconciliation is monitored 

and tracked by the Provision of Care 

Committee. 

Y N 

Pharmacy Operations and CS Inspections 

3. Ensure that controlled CS program 

oversight is effective and that monthly 

inspections comply with VHA regulations. 

We assigned additional staff to ensure 

effective oversight of the CS program. 

Monthly inspections are in place. 

Y N 

4. Ensure that competency assessments of 

all CS inspectors are completed. 

We completed competency 

assessments of all CS inspectors, and 

these remain current. 

Y N 

EOC 

5. Address identified security and safety 

issues appropriately, and implement action 

plans. 

We implemented monthly audits, and 

data show full compliance with security 

and safety requirements. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Appendix B 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

ED and Urgent Care Center Operations 

6. Ensure that documentation of all 

inter-facility transfers complies with VHA and 

facility policy and that patient transfers are 

monitored and evaluated. 

Inter-facility transfer documentation 

has been tracked and monitored. 

Periodic audits show good compliance 

with policy. 

Y N 

Medication Management 

7. Ensure that nurses consistently document 

the effectiveness of all pain medications within 

the required timeframe. 

Reassessments are conducted and 

documented within the required 2-hour 

timeframe. 

Y N 

Coordination of Care 

8. Ensure that patient understanding of 

discharge instructions is documented. 

The discharge template was modified, 

and compliance is monitored through 

quarterly audits of patient records. 

Recent audits show good compliance 

with requirements. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

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 72.2 62.9 73.3 66.7 51.1 55.5 56.0 56.8 

VISN 70.5 65.7 72.9 70.2 57.8 58.6 59.3 56.9 

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 10 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

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

conditions6 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 CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 11.17 9.88 12.95 19.28 19.83 13.86 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

6 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 11 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 June 2, 2011 

From:	 Director, Sierra Pacific Network (10N21) 

Subject:	 CAP Review of the VA Northern California Health Care 

System, Sacramento, CA 

To:	 Director, Los Angeles Healthcare Inspections Division 

(54LA) 

Director, Management Review Service 

1.	 Thank you for the opportunity to review the draft OIG CAP report for 

the Northern California Health Care System site visit that was 

conducted during the week of April 11, 2011. Recommendations that 

were made by the team were valid and we concur with those 

recommendations. My staff will ensure completion of their action plans 

as described in the attachment by the established target dates. 

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

Terry Sanders, VISN 21 Associate Quality Management Officer, at 

(707) 562-8370. 

(original signed by:) 

Sheila M. Cullen 

Attachments 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 May 20, 2011 

From:	 Director, VA Northern California Health Care System 

(612/00) 

Subject:	 CAP Review of the VA Northern California Health Care 

System, Sacramento, CA 

To:	 Director, Sierra Pacific Network (10N21) 

1.	 Thank you for the opportunity to review the OIG report on the CAP 

Review of Northern California Health Care System. We concur with 

the recommendations and will ensure completion as described in the 

implementation plan. 

2.	 Please find attached our responses to each recommendation provided 

in the attached implementation plan. 

3.	 If you have any questions regarding the response to the 

recommendations in the report, feel free to call me at (916) 843-9058. 

(original signed by:) 

William Cahill, MD 

for 

Brian J. O’Neill, M.D. 

Director, Northern California Health Care System 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

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 timeframes be clearly documented on 

physicians’ FPPE forms and that FPPE results be reported to the MEC. 

Concur 

Target date for completion: August 30, 2011 

FPPE form to be revised to include; criteria for conducting the performance evaluation, 

method of establishing the monitoring plan specific to the requested privilege, method to 

determining the duration of the performance monitoring, and circumstances under which 

monitoring by an external sources is required. Form will be approved by the Medical 

Staff to ensure consistent implementation. FPPE results will be reviewed during the 

Credentialing and Privileging (C&P) Committee, discussion and recommendations will 

be captured in the minutes. C&P Committee minutes regarding FPPE results will be 

presented to Medical Executive Council (MEC) for further input as appropriate. 

Education will be provided to the medical staff on implementation. 

Recommendation 2. We recommended that at the time of reprivileging, MEC meeting 

minutes document discussion of performance data for all physicians. 

Concur 

Target date for completion: September 20, 2011 

Reviews of performance data will be conducted at the time of reprivileging and 

discussion documented in the minutes of the Credential and Privileging (C&P) 

Committee. The minutes of the C&P committee, as well as, C&P committee 

recommendations and supporting performance data will be presented at Medical 

Executive Council (MEC) for further review and discussion. The MEC minutes will 

reflect the discussion and decision on concurrence with the C&P Committee 

recommendations. 

Recommendation 3. We recommended that annual N95 respirator fit testing be 

completed and that compliance be monitored. 

Concur 

Target date for completion: July 1, 2011 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Industrial Hygienist responsible for conducting N95 Fit Testing for NCHCS employees 

collaborated with the services across all sites of NCHCS to develop a comprehensive 

list of individuals and roles of staff requiring N95 Fit Testing. The final employee list will 

be reviewed on a quarterly basis with the services to ensure it is maintained current and 

testing is conducted as indicated. N95 Fit Testing will be provided to those individuals 

identified who have not yet been tested by July 1, 2011. Compliance of N95 Fit Testing 

will be monitored and reported to the Infection Control Committee on a monthly basis. 

Recommendation 4. We recommended that all laser users complete laser safety 

training and that compliance be monitored. 

Concur 

Target date for completion: July 1, 2011 

A review of laser procedures throughout NCHCS was conducted. The Laser Safety 

Officer (LSO) has developed a laser procedure inventory tracking log to ensure all laser 

procedures and laser users have been identified. Annual Laser Safety Training has 

been provided to laser users by the LSO. The LSO will provide Laser Safety training at 

least twice a year and as needed to ensure all laser users have received Laser Safety 

training initially prior to laser use and annually thereafter. LSO will review the laser 

procedure inventory tracking log with the Services not less than twice a year to ensure 

the inventory of procedures and laser users is accurate. LSO will track the training of 

the laser users to ensure they have completed the training annually and report the 

compliance to the Safety Committee on a quarterly basis. 

Recommendation 5. We recommended that facility IC policy be revised to include EN 

IC expectations. 

Concur 

Target date for completion: July 1, 2011 

Nursing Service revised the NCHCS Nursing Service Competency for Enteral Feeding 

Continuous Drip to include the recommended IC exceptions per ASPEN guidelines prior 

to OIG CAP site visit exit. Infection Control and Dietetics have revised the Hazard 

Analysis Critical Control Point (HACCP) Program for Enteral Feeding to include the 

guidelines on; purchase receiving, storage, preparation, administration, and disposition. 

Both documents will be finalized and presented to the organization for awareness and 

training as appropriate by July 1, 2011. 

Recommendation 6. We recommended that safe work practices be observed when 

handling hazardous drugs. 

Concur 

Target date for completion: July 1, 2011 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Education was provided to pharmacy staff regarding proper preparation and 

compounding of hazardous drugs. Pharmacy reviewed SOP, Competency evaluations 

and USP 797 to ensure policy and practice are consistent with the regulatory 

requirements. Staff have been educated to gather all drug and supply items before 

compounding medications to minimize contamination and ensure staff safety according 

to the Pharmacy competency evaluation form. Additional, education regarding proper 

removal of contaminated outer-gloves every time prior to exit and re-enter from the 

hood was given to pharmacy staff on April 15, 2011. Compliance has been monitored 

monthly by the pharmacy supervisor to ensure adherence to technique and procedures. 

Practice compliance has been 100%. Compliance monitoring will continue on a monthly 

basis until July 1 in order to ensure 100% compliance. If compliance is 100% in July, 

monitoring will continue on a quarterly basis and reported to Pharmacy Quality 

Committee for oversight. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

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	 Daisy Arugay, MT, Project Leader 

Douglas Henao, RD, Team Leader 

Simonette Reyes, RN 

Kathleen Shimoda, RN 

Mary Toy, RN 

Julie Watrous, RN 

Mike Seitler, Office of Investigations 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA Northern California Health Care System, Sacramento, CA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Sierra Pacific Network (10N21) 

Director, VA Northern California Health Care System (612/00) 

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: Barbara Boxer, Dianne Feinstein
 

U.S. House of Representatives: John Garamendi, Wally Herger, Barbara Lee,
 

Daniel E. Lungren, Doris O. Matsui, George Miller, Fortney Pete Stark, Mike Thompson
 

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

VA OIG Office of Healthcare Inspections 18