Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01297-222 

Combined Assessment Program
 

Review of the
 

Cheyenne VA Medical Center
 

Cheyenne, Wyoming
 

July 12, 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 Cheyenne VA Medical Center, Cheyenne, WY 

Glossary 

AD advance directive 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CLC community living center 

COC coordination of care 

EMR electronic medical record 

EN enteral nutrition 

EOC environment of care 

facility Cheyenne VA Medical Center 

FPPE Focused Professional Practice Evaluation 

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 Cheyenne VA Medical Center, Cheyenne, WY 

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
 

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

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

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

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

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

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

Management of Workplace Violence................................................................. 5
 

Medication Management ................................................................................... 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 ......................................................... 16
 

G. Report Distribution ............................................................................................ 17
 

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

Review of the Cheyenne VA Medical Center, Cheyenne, WY 

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 

May 9, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

 Enteral Nutrition Safety 

 Management of Workplace Violence 

 Medication Management 

 Registered Nurse Competencies 

The facility’s reported accomplishments 

were the Compensation and Pension 

Examination Redesign Project, which 

reduced the examination waiting time 

from 35 to 15 days or less, and the 

mobile tele-health clinic, which provides 

weekly primary care and mental health 

tele-health services to more than 

900 veterans in 5 rural communities. 

Recommendations: We made 

recommendations in the following four 

activities: 

Quality Management: Require that 

airway assessments are documented 

prior to procedures requiring moderate 

sedation and that compliance is 

monitored. Consistently monitor the use 

of the copy and paste functions in the 

electronic medical record. 

Physician Credentialing and Privileging: 

Ensure that Focused Professional 

Practice Evaluations are completed for 

all newly hired physicians and that 

results are reported to the Executive 

Committee of the Medical Staff. 

Environment of Care: Ensure that 

annual N95 respirator fit testing and 

bloodborne pathogens training are 

completed and that compliance is 

monitored. 

Coordination of Care: Require that the 

local policy for management of advance 

care planning/advance directives is 

consistent with current Veterans Health 

Administration policy and that 

compliance with the policy is monitored. 

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 Cheyenne VA Medical Center, Cheyenne, WY 

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: 

	 COC 

	 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 May 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 Cheyenne VA Medical 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Center, Cheyenne, Wyoming, Report No. 08-02413-34, 

December 3, 2008). The facility had corrected all findings. 

(See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 96 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
 Compensation and 

Pension 

Examination 

Redesign Project 

Mobile Tele-Health 

Clinics 

In early FY 2010, the completion rate for compensation and 

pension examinations exceeded the national goal of 30 days 

by an average of 5 days. To improve the efficiency and 

quality of the examinations, the facility chartered a systems 

redesign team whose main goal was to reduce examination 

wait times to less than 30 days. 

By December 2010, the team had met the goal and 

subsequently set a new goal to reduce the examination wait 

times to 14 days. In January 2011, examination wait times 

were 15 days or less. The facility is now applying lessons 

learned from this redesign project to other redesign projects. 

To expand services to rural veterans, the facility opened a 

mobile tele-health clinic in August 2009. The clinic provides 

weekly primary care and mental health tele-health services 

as well as nursing care and laboratory services. It serves 

771 veterans located in Torrington, Wheatland, Sterling, and 

Laramie, WY. The facility also opened a mobile tele-health 

clinic in Rawlins, WY, to serve an additional 221 veterans. 

The Rawlins clinic provides primary care and mental health 

services, tele-health weight management, and tele-retinal 

imaging. It also provides nursing care and laboratory 

services. 

Results 

Review Activities With Recommendations 

QM The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following areas that needed 

improvement. 

Moderate Sedation. VHA requires providers to document a 

complete history and physical within 30 days of a procedure 

and to re-evaluate the patient immediately prior to sedation.1 

These evaluations must include an assessment of the 

airway. We reviewed the medical records of 10 patients who 

underwent selected procedures where moderate sedation 

was used and found that 9 of the pre-sedation evaluations 

did not contain airway assessments. 

Medical Record Review. VHA requires that each facility 

monitor the use of the copy and paste functions in the EMR.2 

In January 2011, the facility implemented a process to 

monitor open and closed medical records on an ongoing 

basis. Prior to this time, the facility did not consistently 

monitor the use of the copy and paste functions in the EMR. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that airway assessments are documented prior to 

procedures requiring moderate sedation and that compliance 

be monitored. 

2. We recommended that the use of the copy and paste 

functions in the EMR be consistently monitored. 

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 area that needed improvement. 

FPPE. VHA requires that an FPPE be completed for all 

physicians who have been newly hired and that the results 

be reported to the Executive Committee of the Medical 

1 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 2 VHA Handbook 1907, Health Information Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Staff.3 One of four newly hired physicians did not have an 

FPPE implemented. Additionally, results for the three 

completed FPPEs were not reported to the Executive 

Committee of the Medical Staff. 

Recommendation	 3. We recommended that FPPEs be completed for all 

newly hired physicians and that FPPE results be reported to 

the Executive Committee of the Medical Staff. 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the medical/surgical, intensive care, and post 

acute care units; the CLC; the eye and dental outpatient 

clinics; and the emergency department. 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 employees with occupational 

exposure risk receive annual training on the Bloodborne 

Pathogens Rule. We reviewed 25 employee training records 

and found that 20 employees did not have this training 

documented. 

If facilities use N95 respirators, the Occupational Safety and 

Health Administration requires that designated employees 

are fit tested annually. We reviewed 25 employee training 

records and found that 19 designated employees did not 

have the required annual fit testing. 

Recommendation	 4. We recommended that annual bloodborne pathogens 

training and N95 respirator fit testing be completed and that 

compliance be monitored. 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning and ADs in 

accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of AD 

notification, AD screening, and documentation of advance 

care planning discussions. We also reviewed the facility’s 

policy to determine whether it was consistent with VHA 

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

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

policy. We identified the following area that needed 

improvement. 

Advance Care Planning/AD Policy. VHA requires that health 

care staff follow specific procedures for advance care 

planning/ADs. Local policy was not consistent with current 

VHA policy. Patient notification of the right to accept or 

refuse medical treatment, to designate a Health Care Agent, 

or to document treatment preferences in an AD was not 

consistently documented. Additionally, staff did not 

consistently: 

 Ensure appropriate witnesses signed ADs created 

using the VA form. 

 Ensure AD notes were linked to the current ADs in the 

EMR. 

 Document patients received a hard copy of the AD 

when the AD was created using the VA form. 

 Use correct progress note titles. 

Recommendation	 5. We recommended that local policy for management of 

advance care planning/ADs be consistent with current VHA 

policy and that compliance with the policy be monitored. 

Review Activities Without Recommendations
 

EN Safety	 The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. While conducting the EOC review, 

we also inspected areas where EN products were stored, 

and we interviewed key employees. We determined that the 

facility generally met EN safety 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 workplace violence policy and 

managed the assaults in accordance with policy. The 

training plan addressed the required prevention and 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

management of disruptive behavior training. We made no 

recommendations. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, 

transportation, 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 clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. 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 policy and processes, 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 ensure that RN competencies were assessed and 

validated 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 12–15, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Appendix A 

Facility Profile4 

Type of Organization Medical center 

Complexity Level 3 

VISN 19 

Community Based Outpatient Clinics Greeley, CO 

Ft. Collins, CO 

Sidney, NE 

Veteran Population in Catchment Area 68,800 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

21 hospital 

 CLC/Nursing Home Care Unit 50 

 Other N/A 

Medical School Affiliation(s) University of Wyoming Family Practice 

 Number of Residents 6 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

February 2011) 

$107.5 

Prior FY (2010) 

$108.5 

 Medical Care Expenditures $84.3 $83.1 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

603 

14,749 

2,743 

582 

18,329 

5,655 

o CLC/Nursing Home Care Unit 5,994 13,657 

Hospital Discharges 509 1,312 

Total Average Daily Census (including all bed 

types) 

16.4 hospital 

39.7 CLC 

15.5 hospital 

37.4 CLC 

Cumulative Occupancy Rate (in percent) 78.7 74.3 

Outpatient Visits 95,497 201,690 

4 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure QM data is trended, analyzed, 

and reported to the appropriate oversight 

board. 

Minute taking education was provided 

for those taking minutes, and a minute 

template was distributed. Also, a 

committee reporting structure was 

finalized with appropriate routing to 

oversight boards. 

Y N 

2. Ensure adverse events are documented 

and communicated. 

Adverse event disclosures are now 

tracked by the patient safety manager. 

Y N 

EOC 

3. Ensure emergency carts are checked. A survey readiness Tier Three Tracer 

Program monitors and provides 

education regarding emergency cart 

checks. 

Y N 

4. Ensure medication refrigerators are 

monitored. 

A survey readiness Tier Three Tracer 

Program monitors and provides 

education regarding refrigerator 

checks. We are currently obtaining 

bids for a centralized temperature and 

humidity monitoring system. 

Y N 

5. Ensure hand hygiene compliance data is 

collected. 

A survey readiness Tier Three Tracer 

Program monitors and provides 

education regarding hand hygiene. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

COC 

6. Ensure complete discharge 

documentation. 

Chart review forms were updated to 

include discharge documentation, and 

discharge policies were updated. 

Y N 

Emergency/Urgent Care Operations 

7. Ensure complete inter-facility transfer 

documentation. 

An additional signer was added to the 

transfer form, and completed 

documentation is verified by the RN 

Assistant Manager. The Emergency 

Department/Ambulatory Care Manager 

reviews the data. 

Y N 

Pharmacy Operations 

8. Appoint a non-clinical Controlled 

Substance Coordinator. 

A non-clinical Controlled Substance 

Coordinator is currently appointed. 

Y N 

9. Ensure the Facility Director signs 

appointment letters for controlled substances 

inspectors. 

The Director signs all appointment 

letters. 

Y N 

10. Repair the pharmacy vault day gate. The pharmacy vault day gate was 

repaired. 

Y N 

11. Ensure pharmacy refrigerator 

temperatures are monitored and documented. 

A survey readiness Tier Three Tracer 

Program monitors and provides 

education regarding refrigerator 

checks. An action group is currently in 

place and obtaining bids for a 

centralized temperature and humidity 

monitoring system. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

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 69.4 69.3 71.9 68.8 68.2 61.1 50.6 55.4 

VISN 65.9 62.5 64.0 65.5 53.9 52.8 52.6 52.3 

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 Cheyenne VA Medical Center, Cheyenne, WY 

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

conditions5 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 * 9.34 13.19 * 21.04 14.99 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

* Not enough cases 

5 Congestive heart failure is a weakening of the heart’s pumping power. With heart failure, the 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 the lungs with mucus and causes difficulty breathing, fever, cough, 

and fatigue. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 21, 2011
 

From: Director, Rocky Mountain Network (10N19)
 

Subject: CAP Review of the Cheyenne VA Medical Center,
 

Cheyenne, WY 

To: Director, Denver Office of Healthcare Inspections (54DV) 

Director, Management Review Service (10A4A4) 

I have reviewed and concur on the attached response from the Cheyenne 

VAMC regarding the Draft Report of the Combined Assessment Program 

Review. If you have any additional questions, please contact 

Ms. Susan Curtis, VISN 19 HSS at (303) 639-6995. 

Director, Rocky Mountain Network (10N19) 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 June 16, 2011 

From:	 Director, Cheyenne VA Medical Center (442/00) 

Subject:	 CAP Review of the Cheyenne VA Medical Center, 

Cheyenne, WY 

To:	 Director, Rocky Mountain Network (10N19) 

1. The Cheyenne VAMC would like to express our appreciation for the 

opportunity to work with the Office of Inspector General and to review the 

report on the CAP Review of the Cheyenne VA Medical Center. 

2. Please find attached our response to each recommendation provided 

in the report. 

3. If there are any questions regarding the response to the 

recommendations or any additional information is required, please contact 

Ms. Lisa Adamson, Chief of Quality Management, (307) 433-3621 or at 

Lisa.Adamson@va.gov. 

Attachments: 

1. Comments to the Office of Inspector General’s Report 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

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 processes be strengthened to ensure that 

airway assessments are documented prior to procedures requiring moderate sedation 

and that compliance be monitored. 

Concur 

Target date for completion: May 11, 2011 

An airway assessment tool was added to the template for moderate sedation history 

and physical documentation. The providers have been educated regarding use of this 

template. Furthermore, the documentation in the chart will be monitored and tracked 

monthly and results reported to Medical Record Committee. 

Recommendation 2. We recommended that the use of the copy and paste functions in 

the EMR be consistently monitored. 

Concur 

Target date for completion: June 7, 2011 

Monitoring of the copy and paste functions in the EMR have been added to the monthly 

chart review forms and reported by each department to the Medical Record Committee. 

This information will be reported quarterly to the Medical Executive Board for analysis 

and action. 

Recommendation 3. We recommended that FPPEs be completed for all newly hired 

physicians and that FPPE results be reported to the Executive Committee of the 

Medical Staff. 

Concur 

Target date for completion: June 7, 2011 

This recommendation was presented to the Medical Executive Board on June 7, 2011. 

All newly hired physicians requesting privileges or requests for new privileges presented 

to the Medical Executive Board will be accompanied by an FPPE plan and timeline. 

The minutes have been updated to include the tracking of FPPE to closure. 

Administrative Officers for the clinical service lines will be tracking the FPPE timelines to 

ensure completion. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Recommendation 4. We recommended that annual bloodborne pathogens training 

and N95 respirator fit testing be completed and that compliance be monitored. 

Concur 

Target date for completion: July 30, 2011 

Bloodborne Pathogen training is being monitored by the DLO and will be uploaded into 

TMS for tracking of completion. Currently 5% have completed training. 

Staff required by current policy have been trained in the proper use, fitting instructions, 

inspection, storage, and respirator limitations of the Powered Air Purifying Respirator 

system and/or the N95 masks. In addition, a fit testing team has been developed and 

trained to provide fit testing. These staff will be available if the need should arise for 

additional fit testing of staff for either the Powered Air Purifying Respirator system or the 

N95 masks. The completion of this training is being entered into TMS for compliance 

monitoring and reminder to staff and supervisor. 

Recommendation 5. We recommended that local policy for management of advance 

care planning/ADs be consistent with current VHA policy and that compliance with the 

policy be monitored. 

Concur 

Target date for completion: July 15, 2011 

The Cheyenne VAMC Advance Directive policy memorandum has been updated to be 

consistent with the current VHA directive and is currently in the concurrence process. 

Training was completed for 100% of scanning staff on how to link reports and when to 

contact Social Work regarding issues with Advance Directives. An audit will be 

completed in approximately six (6) months to monitor compliance. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

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 Stephanie Hensel, RN, JD, Project Leader 

Cheryl Walker, FNP, MBA, Team Leader 

Clarissa Reynolds, CNHA, MBA 

Ann Ver Linden, RN, MBA 

Laura Dulcie, BSEE, Lead Program Specialist 

Randy Rupp, Resident Agent In Charge, Office of Investigations 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Cheyenne VA Medical Center, Cheyenne, WY 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Rocky Mountain Network (10N19) 

Director, Cheyenne VA Medical Center (442/00) 

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: John Barrasso, Michael F. Bennet, Michael B. Enzi, Mike Johanns, 

Ben Nelson, Mark Udall 

U.S. House of Representatives: Cory Gardener, Cynthia M. Lummis, Adrian Smith 

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

VA OIG Office of Healthcare Inspections 17