Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02081-09 

Combined Assessment Program
 

Review of the
 

Fayetteville VA Medical Center
 

Fayetteville, North Carolina
 

October 27, 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 Fayetteville VA Medical Center, Fayetteville, NC 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

COC coordination of care 

ED emergency department 

EN enteral nutrition 

EOC environment of care 

facility Fayetteville VA Medical Center 

FY fiscal year 

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 Fayetteville VA Medical Center, Fayetteville, NC 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

Physician C&P................................................................................................... 2
 

QM..................................................................................................................... 3
 

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

RN Competencies ............................................................................................. 5
 

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

Review Activities Without Recommendations ......................................................... 6
 

COC .................................................................................................................. 6
 

Management of Workplace Violence................................................................. 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 ......................................................... 18
 

G. Report Distribution ............................................................................................ 19
 

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

Review of the Fayetteville VA Medical Center, Fayetteville, NC 

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 

July 11, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following two 

activities: 

 Coordination of Care 

 Management of Workplace Violence 

The facility’s reported accomplishments 

were its strong resource sharing 

partnership with Womack Army Medical 

Center and gynecological continuity of 

care for the female veteran population. 

Recommendations: We made 

recommendations in the following five 

activities: 

Physician Credentialing and Privileging: 

Correct privilege form irregularities, and 

ensure privilege forms are completed 

appropriately. Ensure that Focused and 

Ongoing Professional Practice 

Evaluation forms contain results of the 

data analyzed. Require privileges to 

comply with Veterans Health 

Administration requirements. 

Quality Management: Ensure that all 

services provide the required medical 

record reviews and that the reviews 

include all required components. 

Require medical record review 

processes to include monitoring the 

copy and paste functions. 

Environment of Care: Complete N95 

respirator fit testing and bloodborne 

pathogens training annually, and 

monitor compliance. Ensure that the 

security of crash cart locks is checked 

and documented in accordance with 

local policy and that compliance is 

monitored. 

Registered Nurse Competencies: 

Ensure that competency documents 

contain all required signatures and 

dates. 

Enteral Nutrition Safety: Ensure that all 

nasogastric tube placements are 

confirmed with x-rays prior to initiating 

feedings. 

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 Fayetteville VA Medical Center, Fayetteville, NC 

Objectives and Scope
 

Objectives
 

Scope
 

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

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

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 COC 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through July 11, 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 Fayetteville VA Medical Center, 

Fayetteville, North Carolina, Report No. 08-01447-68, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

February 17, 2009). (See Appendix B for further details.) 

The facility had a repeat finding in the area of QM. 

During this review, we also presented crime awareness 

briefings for 137 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
 Sharing 

Partnership 

Gynecological 

Continuity of Care 

The facility and Womack Army Medical Center enjoy a strong 

resource sharing partnership with goals to improve access to 

care and cost savings. Veterans from the facility have 

access to Womack’s vascular surgery, urology, orthopedics, 

and gynecology services. In addition, staff from Womack 

train at the facility for sleep study certification and 

reciprocated nurse training, and staff from the facility train at 

Womack for out-of-operating room airway management. 

During FY 2010, the facility saved $98,971 through this 

partnership. 

The facility increased the continuity of care for the female 

veteran population by purchasing new equipment, which 

allows them to meet routine and complex gynecological 

needs. The facility also entered into a sharing agreement 

with Womack Army Medical Center that allows the facility’s 

staff gynecologist to perform complex gynecological 

surgeries at Womack. These surgeries were previously 

contracted out to the local civilian hospital. 

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 12 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. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Privilege Forms. VHA requires privilege forms to conform to 

certain formats.1 Five of the 12 privilege request forms we 

reviewed did not contain all the required elements. For 

example, some of the forms had blank signature blocks and 

missing initials. 

Focused and Ongoing Professional Practice Evaluation. 

VHA requires that data consistent with service-specific 

competency criteria be collected, maintained in each 

physician’s profile, and reviewed on an ongoing periodic 

basis.2 Five of the 12 physician profiles reviewed had 

Focused and Ongoing Professional Practice Evaluation 

forms that lacked documentation of the data analyzed. 

Privileges. VHA requires that privileges granted to a 

physician be specific to the facility, service, setting, and 

provider.3 We found that 7 of the 12 provider profiles 

reviewed did not comply with VHA requirements. For 

example, one provider lacked privileges for the type of care 

provided, and another provider had privileges that were 

outside the scope of practice for that clinic. 

Recommendations	 1. We recommended that privilege form irregularities be 

corrected and that processes be strengthened to ensure that 

privilege forms are completed appropriately. 

2. We recommended that processes be strengthened to 

ensure that Focused and Ongoing Professional Practice 

Evaluation forms contain results of the data analyzed. 

3. We recommended that privileges comply with VHA 

requirements. 

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 area that needed 

improvement. 

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

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include specific areas of review 

and to monitor the copy and paste functions.4 We found that 

multiple services did not provide the required medical record 

reviews and that medical record reviews did not include all of 

the required components. For example, we found that from 

July 2010 until January 2011, the facility did not review any 

service-level reports. This was a repeat finding from the 

previous CAP review. In addition, the facility did not monitor 

the copy and paste functions in the electronic medical 

record. 

Recommendations	 4. We recommended that processes be strengthened to 

ensure that all services provide the required medical record 

reviews and that the reviews include all required 

components. 

5. We recommended that medical record review processes 

be strengthened to ensure that the copy and paste functions 

are monitored. 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected a community living center, same day surgery, 

the post-anesthesia care unit, behavioral health, and the 

medical-surgical and intensive care units. We also inspected 

the dental clinic and a combined primary care clinic/ED. 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 designated employees be fit 

tested annually if the facility uses N95 respirators. We 

reviewed 25 employee training records and determined that 

24 employees did not have the required annual fit testing. 

The Occupational Safety and Health Administration requires 

that employees with occupational exposure risk receive 

annual training on the Bloodborne Pathogens Rule. We 

reviewed 14 employee training records and found that 

3 employees did not have this training documented. 

4 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Recommendations 

RN Competencies 

Recommendation 

EN Safety 

Medication Security. Local policy requires that crash cart 

lock security be checked and documented once during each 

tour of duty in areas where 24-hour service is provided. 

Emergency medications are stored in locked crash carts 

located in strategic locations throughout the facility. We 

found crash carts in three different areas (the ED, behavioral 

health, and the intensive care unit) that did not have the 

required documentation for several tours of duty during the 

past month. 

6. We recommended that N95 respirator fit testing and 

bloodborne pathogens training be completed annually and 

that compliance be monitored. 

7. We recommended that the security of crash cart locks 

be checked and documented in accordance with local policy 

and that compliance be monitored. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policy, interviewed nurse leaders, and 

reviewed initial and ongoing competency assessment and 

validation documents for 12 RNs. We identified the following 

area that needed improvement. 

Competency Validation Documentation. Local policy 

requires that both the employee and supervisor sign the 

competency document. In addition, the supervisor and the 

employee must sign and date each item in the document. 

Ten out of the 12 RN competency folders reviewed had 

missing signatures and/or missing dates. 

8. We recommended that processes be strengthened to 

ensure that competency documents contain all required 

signatures and dates. 

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. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

X-Ray Confirmation. VHA requires that health care staff 

confirm placement of a nasogastric tube with an x-ray prior to 

using the tube for feeding.5 We reviewed the medical 

records of 15 patients. Of the 10 applicable patients, we 

found that 3 intensive care unit patients with nasogastric 

tubes did not have the required x-ray confirmation prior to 

initiating feedings via the tube. 

Recommendation	 9. We recommended that processes be strengthened to 

ensure that all nasogastric tube placements are confirmed 

with x-rays prior to initiating feedings. 

Review Activities Without Recommendations
 

COC	 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 

generally met VHA requirements. We made no 

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. 

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 management of 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. 

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 12–17 for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

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

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Appendix A 

Facility Profile6 

Type of Organization Medical center – non tertiary care 

Complexity Level 3 

VISN 6 

Community Based Outpatient Clinics Hamlet, NC 

Jacksonville, NC 

Robeson County (Pembroke), NC 

Wilmington, NC 

Veteran Population in Catchment Area 187,338 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

56 

 Community Living Center/Nursing 

Home Care Unit 

49 

 Other N/A 

Medical School Affiliation(s) Duke-Southern Regional Area Health 

Education Center (SR-AHEC) 

East Carolina University 

Womack Army Medical Center 

 Number of Residents 8 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

March 2011) 

$98.3 

Prior FY (2010) 

$171.5 

 Medical Care Expenditures $88.8 $171.5 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

889 

40,245 

6,912 

810 

47,463 

13,500 

o Community Living 

Center/Nursing Home Care Unit 

8,315 18,348 

Hospital Discharges 1,218 2,712 

Total Average Daily Census (including all bed 

types) 

84 87 

Cumulative Occupancy Rate (in percent) 64.9 67.6 

Outpatient Visits 198,640 389,072 

6 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Require Facility Management Service to 

conduct a facility-wide cleaning project and 

to increase monitoring of routine cleaning. 

A facility-wide cleaning project was 

completed December 19, 2008. A 

cleaning schedule was developed for 

routine and deep cleaning. Cleaning is 

monitored through EOC rounds and 

reported to the EOC Committee. 

Y N 

2. Require Engineering Service to monitor 

the completion of work orders for timeliness. 

Facility policy was updated with a new 

classification for work orders. Work 

order completion is tracked for 

timeliness by the EOC Committee. 

Y N 

3. Document regular testing of the 

WanderGuard® system. 

The Associate of Patient Care Services 

for Long Term Care ensures that 

testing of the WanderGuard® system 

occurs and is documented daily. 

Compliance is reported to the Nurse 

Executive Committee. 

Y N 

4. Store clean linen appropriately. Nurse managers conduct random 

checks and report results to the Nurse 

Executive Committee. 

Y N 

QM 

5. Ensure committee meeting minutes 

comply with facility policy. 

A new policy and meeting minutes 

format were implemented, and the new 

format is in use by most committees. 

Y N 

6. Ensure the peer review process complies 

with facility policy. 

Quarterly peer review activities are 

reported to the Medical Executive 

Board. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

7. Ensure the Utilization Management 

Committee meets as required. 

The Utilization Management 

Committee meets at least six times a 

year. 

Y N 

8. Monitor and evaluate moderate sedation 

outcomes. 

Moderate sedation outcomes are 

monitored quarterly by the Operative 

and Other Invasive Procedure 

Committee. 

Y N 

9. Monitor resuscitation outcomes. Resuscitation outcomes are reported 

monthly to the Critical Care Committee. 

Y N 

10. Conduct medical record reviews in 

accordance with VHA policy. 

Medical record reviews have not been 

consistently completed by the Medical 

Records Committee. 

N Y (see page 4) 

COC 

11. Complete discharge documentation as 

required by VHA policy 

Discharge documentation training was 

completed, and the discharge 

instruction template was modified to 

automatically incorporate outpatient 

medications. Clinical services monitor 

compliance and report findings to the 

Medical Records Committee quarterly. 

Y N 

Emergency/Urgent Care Operations 

12. Maintain privacy in the ED. Patient privacy screens are in use in 

the temporary ED location. Nursing 

staff in the ED received patient privacy 

education. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

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 

quarters 3 and 4 of FY 2010 and quarters 1 and 2 of FY 2011. 

Table 1 

FY 2010 FY 2011 

Inpatient Score 

Quarters 3–4 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Inpatient 

Score 

Quarters 1–2 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Facility 46.2 44.3 40.2 49.7 37.9 37.7 

VISN 62.0 52.2 46.5 62.8 50.1 49.5 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

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

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

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

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2009 2010 2011 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

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

conditions7 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 * 9.22 13.10 * 21.39 15.64 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

* Not enough cases 

7 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 11 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 October 7, 2011 

From:	 Director, VA Mid-Atlantic Health Care Network (10N6) 

Subject:	 CAP Review of the Fayetteville VA Medical Center, 

Fayetteville, NC 

To:	 Director, Washington, DC, Office of Healthcare Inspections 

(54DC) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

1. The attached subject report is forwarded for your review and further 

action. I have reviewed the responses and concur with the facility’s 

recommendations. 

2. Please contact Elizabeth Goolsby, Director, Fayetteville VA Medical 

Center, at 901-822-7059, if you have any further questions. 

(original signed by:) 

DANIEL F. HOFFMANN, FACHE 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: October 4, 2011
 

From: Director, Fayetteville VA Medical Center (565/00)
 

Subject: CAP Review of the Fayetteville VA Medical Center,
 

Fayetteville, NC 

To: Director, VA Mid-Atlantic Health Care Network (10N6) 

Fayetteville VA Medical Center concurs with findings. We have provided 

the specific corrective actions we have taken for each recommendation 

and clarification of action items (1) and (9) as requested. 

(original signed by:) 

ELIZABETH GOOLSBY 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

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 privilege form irregularities be corrected 

and that processes be strengthened to ensure that privilege forms are completed 

appropriately. 

Concur 

Target completion date: November 30, 2011 

Response: The Fayetteville VAMC (FVAMC) Director concurs with the findings and 

submits the following action plan. 

A review of 100% of the Credentialing and Privileging files has been scheduled to 

ensure inconsistencies with missing signatures and initials are corrected. This review 

will be completed by Nov 30th, 2011. 

To conduct this review, a standardized review form “Initial Application Checklist” will 

be utilized. This form has been revised to incorporate checking for missing signatures 

and initials. 

At the conclusion of the initial review, and to ensure appropriate actions are sustained 

and effective, each credentialing staff member will conduct a random review of five 

C & P files per month utilizing the Initial Application Checklist. The results will be 

reviewed and addressed monthly by the Chief, Performance Improvement and shared 

with leadership as appropriate at Executive Leadership Board meetings. 

Recurrent education and training has been scheduled for the credentialing and 

privileging staff to ensure appropriate completion of the C & P forms and documents. 

This training will be conducted in November 2011. 

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

Focused and Ongoing Professional Practice Evaluation forms contain results of the data 

analyzed. 

Concur 

Target completion date: July 29, 2011 

Response: The FVAMC Director concurred with the findings. A standardized form was 

implemented hospital wide in July 2011 to capture trending and analysis documentation 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

over time and is then maintained in each physician’s profile. Education and training was 

provided to ensure appropriate completion of forms. 

Recommendation 3. We recommended that privileges comply with VHA requirements. 

Concur 

Target completion date: November 2011 

Response: The FVAMC Director concurred with the findings. An inventory of all 

privileges was completed to ensure compliance with all VHA requirements. Privilege 

forms are under review with site specific privileges being addressed to comply with the 

VHA directive. 

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

all services provide the required medical record reviews and that the reviews include all 

required components. 

Concur 

Target completion date: October 31, 2011 

Response: The FVAMC Director concurred with the findings. A review of all required 

medical record reviews and the required components is scheduled to be completed 

during the September 2011 Medical Records Committee meeting. Expectations and 

requirements are also being communicated to the appropriate Service Chiefs. Ongoing 

compliance is monitored in the Medical Executive Board. 

Recommendation 5. We recommended that medical record review processes be 

strengthened to ensure that the copy and paste functions are monitored. 

Concur 

Target completion date: October 31, 2011 

Response: The FVAMC Director concurred with the findings. The requirement for 

compliance with the copy and paste functions has been defined. A memorandum is 

under development to address copy and paste requirement and guidance. Following its 

completion appropriate education and training will occur. Monitoring of this important 

element of the medical records will be ongoing, reported and captured in the Medical 

Records Committee minutes. Data will be trended, analyzed and presented also to the 

Medical Executive Board. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Recommendation 6. We recommended that N95 respirator fit testing and bloodborne 

pathogens training be completed annually and that compliance be monitored. 

Concur 

Target completion date: November 30, 2011 

Response: The FVAMC Director concurred with the findings. An assessment was 

completed in July 2011 to determine staff required to complete fit testing and blood 

borne pathogens training. A three day session was held in August to conduct fit test 

training. Additional sessions are scheduled for completion of the remaining staff as well 

as a routine schedule implemented to ensure achievement of annual requirement. The 

staff fit test compliance and blood borne pathogen training has been added as an 

agenda item in the Infection Prevention Committee to ensure sustained compliance. 

Recommendation 7. We recommended that the security of crash cart locks be 

checked and documented in accordance with local policy and that compliance be 

monitored. 

Concur 

Target completion date: July 29, 2011 

Response: The FVAMC Director concurred with the findings. Process revised in 

July 2011 to ensure services check crash carts daily to ensure security of crash carts. 

Education and training was provided to the services to ensure appropriate compliance. 

Reports of monitoring and compliance will be captured in the Pharmacy and 

Therapeutics Committee minutes and non-compliance related issues will be addressed 

and reported to the Medical Executive Board. 

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

competency documents contain all required signatures and dates. 

Concur 

Target completion date: August 31, 2011 

Response: The FVAMC Director concurred with the findings. All competency folders 

were reviewed and corrected to ensure compliance with the local policy. In addition a 

schedule was established to review competency folders and ensure that all RN 

competencies contain all required signatures and dates. Compliance of this process is 

monitored in the Nurse Executive Committee. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

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

all nasogastric tube placements are confirmed with x-rays prior to initiating feedings. 

Concur 

Target completion date: July 29, 2011 

Response: The FVAMC Director concurred with the findings. The enteral medical 

center policy was developed in July 2011 and includes the requirement for x-ray 

confirmation after nasogastric tube placements prior to initiating feedings. Following its 

completion appropriate education and training occurred. 

An order set, using criteria related to x-ray confirmation requirements has been created 

and is currently in use. A tracking tool was developed using this same criteria. This tool 

is being used to confirm compliance with each nasogastric tube placement. Any 

deviations from practice are addressed daily to the respective discipline. The results 

are reported daily on the Nursing Report and are being discussed at the Nurse 

Executive Committee. This will be reported monthly for six consecutive months 

(stabilization of process) and then quarterly. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

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 Donna Giroux, RN, Project Leader 

Bruce Barnes, Team Leader 

Myra Conway, RN 

Katharine Foster, RN 

Kathy Gudgell, RN, JD 

Julie Watrous, RN 

Natalie Sadow-Colón, MBA, Program Support Assistant 

Robert LaChapelle, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Fayetteville VA Medical Center, Fayetteville, NC 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid-Atlantic Health Care Network (10N6) 

Director, Fayetteville VA Medical Center (565/00) 

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 Burr, Kay R. Hagan 

U.S. House of Representatives: G.K. Butterfield, Renee Ellmers, Walter B. Jones, 

Larry Kissell, Mike McIntyre 

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

VA OIG Office of Healthcare Inspections 19