Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02089-05 

Combined Assessment Program
 

Review of the
 

San Francisco VA Medical Center
 

San Francisco, California
 

October 14, 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 San Francisco VA Medical Center, San Francisco, CA 

Glossary
 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CLC community living center 

ED emergency department 

EN enteral nutrition 

EOC environment of care 

facility San Francisco VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

IC infection control 

MEC Medical Executive Committee 

MM medication management 

OSHA Occupational Health and Safety Administration 

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 San Francisco VA Medical Center, San Francisco, CA 

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
 

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

EOC................................................................................................................... 5
 

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

MM .................................................................................................................... 6
 

Review Activities Without Recommendations ......................................................... 7
 

Coordination of Care ......................................................................................... 7
 

Management of Workplace Violence................................................................. 7
 

Comments................................................................................................................... 7
 

Appendixes 

A. Facility Profile .................................................................................................... 8
 

B. Follow-Up on Previous Recommendations........................................................ 9
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 11
 

D. VISN Director Comments .................................................................................. 13
 

E. Facility Director Comments ............................................................................... 14
 

F. OIG Contact and Staff Acknowledgments ......................................................... 19
 

G. Report Distribution ............................................................................................ 20
 

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

Review of the San Francisco VA Medical Center,
 

San Francisco, 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 

August 8, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

 Coordination of Care 

 Management of Workplace Violence 

The facility’s reported accomplishments 

were being recognized as a Center of 

Excellence for Primary Care Education 

and implementing the hospitalist 

program. 

Recommendations: We made 

recommendations in the following six 

activities: 

Quality Management: Ensure that 

providers assess and document all 

required elements prior to performing 

moderate sedation and that medical 

record reviews include monitoring of 

unauthenticated progress note addenda. 

Physician Credentialing and Privileging: 

Initiate Focused Professional Practice 

Evaluations for all physicians prior to the 

physicians delivering care, and ensure 

results of the evaluations are reported to 

the Medical Executive Committee. 

Registered Nurse Competencies: 

Identify unit-specific competencies for 

the 2B medical-surgical unit that are 

consistent with nursing assignments. 

Ensure that ongoing competency 

validation documentation is complete, 

current, and legible. 

Environment of Care: Complete annual 

bloodborne pathogens training and 

N95 respirator fit testing, and monitor 

compliance. Ensure appropriate 

disposal of non-sharps waste. 

Enteral Nutrition Safety: Revise facility 

infection control policy to include enteral 

nutrition infection control expectations. 

Medication Management: Require 

pharmacy staff to observe safe work 

practices when handling hazardous 

drugs in the pharmacy compounding 

area. Ensure all infusion clinic nursing 

staff are trained in the safe handling of 

chemotherapy medications. 

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 San Francisco VA Medical Center, San Francisco, 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 

	 MM 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through August 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 San Francisco VA 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Medical Center, San Francisco, California, Report 

No. 08-02445-44, December 15, 2008). The facility had 

corrected all findings from our previous review. (See 

Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 255 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
 Center of 

Excellence for 

Primary Care 

Education 

Hospitalist 

Program 

In January 2011, the facility was recognized as one of five 

Centers of Excellence in Primary Care Education. The 

mission of this center is to develop and implement a model of 

patient-centered education. It brings together health care 

providers and trainees in various disciplines to build core 

knowledge and skills to be applied to individual and shared 

team panels of patients. 

The facility implemented a hospitalist program to provide 

adequate, timely, and efficient care and to improve physician 

trainee education and supervision for all medicine unit 

patients. This program has grown from 1 physician in 

July 2010 to 12 physicians as of August 2011. Benefits 

include increased care coordination for patients with 

substantial discharge barriers, more timely response to 

medicine consult requests, proactive medical management 

support for three surgical services, and increased physician 

involvement with facility improvement efforts. 

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 

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 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

documents. We identified the following areas that needed 

improvement. 

Moderate Sedation. VHA requires providers to assess 

patients and document findings prior to performing moderate 

sedation.1 In 2 of the 10 procedure records reviewed, we did 

not find documented evidence that providers assessed 

patients for all required elements. Missing elements included 

assessment of airway, review of abnormalities of major 

organ systems, and review of current medications. 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include monitoring of 

unauthenticated documentation.2 The facility appropriately 

monitored discharge summaries, operative notes, and 

progress notes; however, we did not find a similar review 

process for unauthenticated progress note addenda. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure providers assess and document all required elements 

prior to performing moderate sedation. 

2. We recommended that processes be strengthened to 

ensure that medical record reviews include monitoring of 

unauthenticated progress note addenda. 

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 FPPEs be initiated for all 

physicians prior to the physicians delivering care and that 

FPPE results be reported to the MEC for consideration in 

making the recommendation on privileges for newly hired 

physicians.3 We reviewed the profiles of five newly hired 

physicians. We found deficiencies in four profiles. For two 

physicians, FPPEs were not initiated prior to the physicians’ 

1 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 2 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 3 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Recommendation 

RN Competencies 

Recommendations 

delivering care, and for three physicians, FPPE results had 

not been reported to the MEC. 

3. We recommended that processes be strengthened to 

ensure that FPPEs are initiated for all physicians prior to the 

physicians delivering care and that FPPE results are 

reported to the MEC. 

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 examined initial and ongoing competency 

assessment and validation documents for 12 RNs. We 

identified the following area that needed improvement. 

Competency Validation Process and Documentation. The 

Joint Commission requires that clinical staff are deemed 

competent to perform their job responsibilities. A 

competency validation policy or process is required for staff 

who provide patient care, treatment, or services. Core 

competencies, such as falls prevention, are skills required for 

all RNs. Unit/position competencies are specific to a 

particular area of patient care, such as an intensive care unit. 

Local procedures require assessment and validation of 

competencies to be done when the RN is hired and then 

annually thereafter. 

We found that unit-specific RN competencies had not been 

identified for the 2B medical-surgical unit. Additionally, 8 of 

the 12 RN competency folders did not contain sufficient 

evidence that core and/or unit-specific competencies were 

validated annually. Furthermore, 7 of the 12 folders had 

validation documentation that was incomplete and/or 

contained illegible signatures. 

4. We recommended that managers identify unit-specific 

RN competencies for the 2B medical-surgical unit that are 

consistent with nursing assignments. 

5. We recommended that processes be strengthened to 

ensure that ongoing RN competency validation 

documentation is complete, current, and legible. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

EOC
 

Recommendations 

EN Safety 

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 selected inpatient (the acute medical-surgical, 

mental health, intensive care, and CLC) units, the same day 

surgery and post-anesthesia care units, the dental and 

plastic surgery clinics, and the ED. The facility maintained a 

generally clean and safe environment. However, we 

identified the following conditions that needed improvement. 

IC. OSHA requires that employees with occupational 

exposure risk receive annual training on the OSHA 

Bloodborne Pathogens Rule. We reviewed 24 employee 

training records and found that 3 employees did not have the 

required training. 

If facilities use N95 respirators, OSHA requires that 

designated employees are fit tested annually. We reviewed 

25 employee training records and determined that 

9 designated employees did not have the required annual fit 

testing. 

Waste Disposal. Local policies and state regulations define 

infectious (biohazardous) waste and sharps waste. Only 

certain medical sharps items (for example, contaminated 

needles, syringes, and scalpel blades) are to be disposed of 

in sharps containers. We found that sharps containers in 

several locations contained non-medical sharps waste (such 

as paper wrappers, plastic items, and alcohol wipes). These 

items should have been disposed of as regular waste. 

6. We recommended that annual OSHA Bloodborne 

Pathogens Rule training and N95 respirator fit testing be 

completed and that compliance be monitored. 

7. We recommended that only sharps items be disposed of 

in sharps containers. 

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, 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

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 hand 

washing prior to EN administration and donning gloves. 

Recommendation	 8. We recommended that facility IC policy be revised to 

include EN IC expectations. 

MM	 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 infusion clinic, 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. Staff must change gloves whenever they 

exit and re-enter the biological safety cabinet and must wear 

clean gloves when handling the final preparation. In the 

pharmacy compounding area, we observed a pharmacy 

technician with contaminated gloves exiting the biological 

safety cabinet and re-entering without changing gloves. 

Local policy requires that employees handling hazardous 

drugs receive training on safe handling of these drugs. 

Nursing managers told us that nursing staff routinely 

transport chemotherapy medications from the pharmacy to 

the infusion clinic for administration. While most infusion 

clinic nursing staff had completed the required training for 

safe handling of chemotherapy medications, we did not find 

documented evidence that all had received this training. 

Recommendation	 9. We recommended that safe work practices be observed 

when handling hazardous drugs in the pharmacy 

compounding area and that all infusion clinic nursing staff be 

trained in the safe handling of chemotherapy medications. 

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

VA OIG Office of Healthcare Inspections 6 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Review Activities Without Recommendations
 

Coordination of 

Care 

Management of 

Workplace 

Violence 

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. 

The purpose of this review was to evaluate whether VHA 

facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

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. 

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 13–18 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 7 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Appendix A 

Facility Profile5 

Type of Organization Tertiary care medical center 

Complexity Level Level 1-A 

VISN 21 

Community Based Outpatient Clinics San Francisco, CA 

San Bruno, CA 

Santa Rosa, CA 

Ukiah, CA 

Clearlake, CA 

Eureka, CA 

Veteran Population in Catchment Area 271,819 enrollees 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

Hospital – 124 

Psychosocial Residential Rehabilitation 

Treatment Program – 9 

 CLC/Nursing Home Care Unit 112 

 Other 0 

Medical School Affiliation(s) University of California, San Francisco 

 Number of Residents 182 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

May 2011) 

$501.0 

Prior FY (2010) 

$460.7 

 Medical Care Expenditures $375.8 $460.7 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

 Acute Care 

2,209.7 

52,738 

21,506 

2,155.6 

56,668 

33,443 

 CLC/Nursing Home Care Unit 20,471 35,247 

Hospital Discharges 3,465 5,548 

Total Average Daily Census (including all bed 

types) 

170.74 188.19 

Cumulative Occupancy Rate (in percent) 

 Acute Care 69.2 67.9 

 CLC/Nursing Home Care Unit 73.5 81.3 

 Psychosocial Residential 

Rehabilitation Treatment 

Program 

71.5 68.9 

Outpatient Visits 357,698 481,415 

5 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

QM 

1. Require consistent documentation of QM 

data analyses discussions, and implement 

and evaluate actions to address problems 

or trends. 

All committees use the MEC minutes 

template showing discussion, actions, 

and follow-up. QM monitors data 

aggregation and discussion elements. 

Y N 

2. Require that a process for 

comprehensive monitoring of medication 

reconciliation is maintained and that actions 

are taken to improve compliance. 

Medication reconciliation is completed 

by providers at admission and 

discharge. Documentation compliance 

is reported to service chiefs monthly 

and to the MEC quarterly. Pharmacy 

reviews of medication reconciliation 

accuracy are reported to the MEC 

quarterly. 

Y N 

3. Require that individual restraint and 

seclusion use are monitored and that 

aggregate restraint data is analyzed for 

trends. 

Nursing reviews restraints and 

seclusion monthly. QM aggregates 

and analyzes the data, and results are 

presented to the MEC and nursing 

leadership quarterly. 

Y N 

Pharmacy Operations and Controlled 

Substance Inspections 

4. Ensure completion of required annual 

training for inspectors assigned to research 

laboratories and completion of competency 

assessments for all controlled substance 

inspectors. 

Inspectors assigned to research 

laboratories have received the required 

training and competency assessments. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance Repeat 

Recommendation? 

Y/N 

EOC 

5. Ensure that actions are taken to address 

identified fire safety, security, and IC 

deficiencies. 

Identified EOC deficiencies have been 

addressed. 

Y N 

6. Comply with required annual training, and 

clarify expectations and responsibilities of 

the team and EOC inspections. 

Multidisciplinary Safety Inspection 

Team members have received the 

required training, and inspection 

expectations have been clarified. 

Y N 

ED and Urgent Care Center Operations 

7. Ensure that actions are taken to correct 

identified EOC deficiencies in the ED. 

The facility has a new ED, and EOC 

deficiencies have been addressed. 

Y N 

8. Require that all inter-facility transfer 

documentation complies with VHA policy 

and that patient transfers are monitored and 

evaluated for compliance. 

Inter-facility transfer documentation 

monitoring data shows compliance with 

policy. 

Y N 

MM 

9. Require that nurses consistently 

document pain medication effectiveness 

within the required timeframe. 

Timely documentation of pain 

medication effectiveness exceeded the 

goal of 85 percent in FY 2010 and 

FY 2011 (through July 2011). 

Y N 

Coordination of Care 

10. Require timely dictation and posting of 

discharge summaries and consistent 

recording of discharge orders in medical 

records. 

The facility monitors timely posting of 

discharge summaries and recording of 

discharge orders in all medical records. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the San Francisco VA Medical Center, San Francisco, 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 

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 69.3 61.7 56.2 63.9 63.2 60.6 

VISN 71.5 59.3 56.9 70.5 60.5 59.4 

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 11 
CAP Review of the San Francisco VA Medical Center, San Francisco, 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 2007–2010. 

Table 2 

Mortality Readmission 

Heart Attack Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 12.15 8.85 9.95 11.68 18.01 14.66 

VHA 12.54 9.24 12.02 12.99 19.66 15.15 

6 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 12 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 October 3, 2011 

From:	 Network Director, VISN 21 (10N21) 

Subject:	 CAP Review of the San Francisco VA Medical Center, 

San Francisco, CA 

To:	 Director, Los Angeles Healthcare Inspections Division 

(54LA) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

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

for the San Francisco VAMC site visit that was conducted during the 

week of August 8, 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 

Ms Terry Sanders, VISN 21 Associate Quality Management Officer at 

(707) 562-8370. 

(original signed by:) 

Sheila M. Cullen 

Attachment 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 September 30, 2011 

From:	 Director, San Francisco VA Medical Center (662/00) 

Subject:	 CAP Review of the San Francisco VA Medical Center, 

San Francisco, CA 

To:	 Network Director, VISN 21 (10N21) 

1.	 I appreciate the opportunity to provide comments to the draft report of 

the Combined Assessment Program (CAP) review of the San 

Francisco VA Medical Center (SFVAMC). I carefully reviewed the 

report, as well as my notes from the exit briefing on August 11, 2011. 

2.	 In brief, I concur with all of the findings and suggested improvement 

actions. As you will note, the vast majority of the actions are well on 

their way to be completed. The remaining proposed remedies will be 

completed in the next few months. 

3.	 I am pleased with the overall inspection results. This only fortifies the 

level of commitment our staff have towards caring for the veteran. 

4.	 In closing, I would like to express my thanks to the CAP review team. 

The team members were professional, comprehensive, and focused. I 

appreciated that the survey team discussed issues. The education 

sessions regarding fraud and abuse awareness were also helpful and 

well received by those who attended. The collective interest and 

efforts of the CAP review team have helped improve our clinical and 

business practices at VAMC San Francisco. 

(original signed by:) 

Lawrence H. Carroll, Director 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Comments to Office of Inspector General’s Report
 

The Director submitted the following comments in response to the recommendations in 

the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that processes be strengthened to ensure 

providers assess and document all required elements prior to performing moderate 

sedation. 

Concur 

Target date of implementation/completion: Three month monitoring period began in 

September and will end November 30, 2011. 

Planned Action: During the timeout performed before every invasive procedure, the IR 

attending is confirming with the IR nurse that the pre-procedure note and pre-sedation 

notes (for those patients receiving moderate sedation) have been signed and completed 

fully. The IR attending and the IR nurse are signing the pre-sedation nursing form 

accordingly. A random sample of 10 records will be reviewed monthly for compliance 

for three months. Compliance will be monitored through the Radiology QI Committee. 

Once the VISN wide template note, titled “Pre-procedure verification checklist,” currently 

under development, has been finalized, successfully piloted and made available to IR, it 

will be used to ensure that the pre-procedure and pre-sedation notes have been 

completed. 

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

medical record reviews include monitoring of unauthenticated progress note addenda. 

Concur 

Target date of implementation/completion: Completed September 9, 2011. 

Monitoring will be ongoing. 

Planned Action: Unauthenticated progress note addenda are being monitored monthly 

by HIMS. Data is being reviewed, analyzed for trends by provider, note type, etc. and 

will be reported to the Medical Records Committee (MRC). As trends are identified, 

corrective actions will be developed and effectiveness of the actions monitored. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Recommendation 3. We recommended that processes be strengthened to ensure that 

FPPEs are initiated for all physicians prior to the physicians delivering care and that 

FPPE results are reported to the MEC. 

Concur 

Target date of implementation/completion: August 12, 2011. 

Planned Action: A new process was implemented in May 2011, prior to the OIG 

survey, to electronically monitor requests for and completion of FPPEs and to assure all 

FPPEs are provided to the MEC for review prior to approval of renewal of privileges. 

However, records from prior to implementation of the new process were not in 

compliance resulting in the above recommendation. This new process was reviewed by 

OIG and found to meet requirements. 

Recommendation 4. 

competencies for the 

assignments. 

We recommended that managers identify unit-specific RN 

2B medical-surgical unit that are consistent with nursing 

Concur 

Target dates of implementation/completion: 

Action #1: Completed September 30, 2011. 

Action #2: December 15, 2011. 

Planned Action: 

(1) Survey compliance with 2011 core competencies and report to AMCD/PCS. 

(2) Nursing is reviewing current core competencies and is updating for 2012. Nurse 

Managers will identify unit specific competencies for their respective units. Develop a 

centralized list of all unit specific competencies. 

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

ongoing RN competency validation documentation is complete, current, and legible. 

Concur 

Target date of implementation/completion: December 15, 2011. 

Planned Action: A new facility policy addressing competency assessment was 

developed, including a template for documentation of competency assessment. The 

template will be implemented and Nurse manager’s will audit unit competency files of 

new nursing staff employees quarterly and results will be reported to Nursing 

Leadership. 95% of all reviewed competency files will contain required unit specific 

core competencies. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Recommendation 6. We recommended that annual OSHA Bloodborne Pathogens 

Rule training and N95 respirator fit testing be completed and that compliance be 

monitored. 

Concur 

Target date of implementation/completion: September 30, 2011. Monitoring will be 

ongoing. 

Planned Action: Reports of compliance for completion of the mandatory Bloodborne 

Pathogens training module will be run from the Talent Management System (TMS) 

every 6 months and provided to supervisors for follow-up with their staff. Environmental 

Health and Safety (EH&S) and Infection Control (IC) will risk stratify staff/staff 

assignments and determine which staff need to be in the TB-N95 Respirator Program to 

assure an accurate and complete staff listing. Continue using contractor support to 

assist with individual staff fit testing. Compliance will be monitored by EH&S and 

reported to both the ICC and the EOC Committees. 

Recommendation 7. We recommended that only sharps items be disposed of in 

sharps containers. 

Concur 

Target date of implementation/completion: September 15, 2011. Monitoring will be 

ongoing. 

Planned Action: Infection Control and EH&S have increased emphasis on the proper 

use of sharps containers in new employee orientation. Nurse Managers have 

specifically reminded their staff to use sharps containers for disposal of sharps only. 

Checking contents of sharps containers has been added as an item to Environment of 

Care (EOC) rounds. EMS will also monitor containers as they are replaced. Violations 

of proper disposal will be reported to the EOC Committee and evaluated for trends and 

action. Monitoring will ensure that 95% of all sharps containers have only proper 

content. 

Recommendation 8. We recommended that facility IC policy be revised to include EN 

IC expectations. 

Concur 

Target date of implementation/completion: August 26, 2011. 

Planned Action: A reference was added to the IC Manual under a new heading, 

Enteral Nutrition. A short IC/EN reference has also been added to the facility policy on 

Enteral & TPN Feeding. References are also in Nursing Service Procedure 

(NSP) 75 and NSP-75A. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Recommendation 9. We recommended that safe work practices be observed when 

handling hazardous drugs in the pharmacy compounding area and that all infusion clinic 

nursing staff be trained in the safe handling of chemotherapy medications. 

Concur 

Target date of implementation/completion: December 15, 2011. 

Planned Action: Pharmacy staff have been re-educated about the importance of 

obtaining and placing all needed drugs/supplies in the Biological Safety Cabinet (BSC) 

prior to preparing chemotherapy, and to change gloves whenever re-entering the BSC. 

All nursing staff who transport chemotherapy will complete an in-service education on 

safe handling of chemotherapy medications. A module on safe handling of 

chemotherapy drugs is being implemented in TMS and added as an element of annual 

mandatory training to the learning plans of staff that transport chemotherapy. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the San Francisco VA Medical Center, San Francisco, 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 

Simonette Reyes, RN, Team Leader 

Douglas Henao, RD 

Kathleen Shimoda, RN 

Mary Toy, RN 

Paul Lore, Office of Investigations 

Michael Seitler, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the San Francisco VA Medical Center, San Francisco, CA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Sierra Pacific Network (10N21) 

Director, San Francisco VA Medical Center (662/00) 

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: Nancy Pelosi, Jackie Speier, Mike Thompson, 

Lynn Woolsey 

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

VA OIG Office of Healthcare Inspections 20