Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
	

Report No. 11-01296-235 

Combined Assessment Program
	

Review of the
	

Central Arkansas Veterans
	

Healthcare System
	

Little Rock, Arkansas
	

August 2, 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 Central Arkansas Veterans Healthcare System, Little Rock, AR 

Glossary
	

C&P credentialing and privileging 

CAP Combined Assessment Program 

CPR cardiopulmonary resuscitation 

EN enteral nutrition 

EOC environment of care 

facility Central Arkansas Veterans Healthcare System 

FY fiscal year 

MEB Medical Executive Board 

OIG Office of Inspector General 

PI performance improvement 

PR peer review 

PSB Professional Standards Board 

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 Central Arkansas Veterans Healthcare System, Little Rock, AR 

Table of Contents
	

Page
	

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

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

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

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

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

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

Medication Management ................................................................................... 2
 

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

Coordination of Care ......................................................................................... 4
 

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

Physician C&P................................................................................................... 7
 

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

EN Safety .......................................................................................................... 7
 

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

RN Competencies ............................................................................................. 8
 

Comments................................................................................................................... 8
 

Appendixes 

A. Facility Profile .................................................................................................... 9
 

B. Follow-Up on Previous Recommendations........................................................ 10
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 13
 

D. VISN Director Comments .................................................................................. 15
 

E. Facility Director Comments ............................................................................... 16
 

F. OIG Contact and Staff Acknowledgments ......................................................... 23
 

G. Report Distribution ............................................................................................ 24
 

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

Review of the Central Arkansas Veterans Healthcare System,
	

Little Rock, AR
	

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 

 Registered Nurse Competencies 

Recommendations: We made 

recommendations in the following five 

activities: 

Medication Management: Adhere to 

requirements related to labeling 

chemotherapy infusions and transport. 

Environment of Care: Revise facility 

medication policy to be consistent with 

Veterans Health Administration policy. 

Secure medication, and grant access 

only to those who distribute or 

administer medication. Ensure annual 

bloodborne pathogens training and 

N95 respirator fit testing are completed, 

and monitor compliance. Ensure 

confidential patient information 

displayed on computer screens is 

protected from unauthorized access. 

Coordination of Care: Ensure all 

components of written advance directive 

notification are provided to patients, and 

document notification. Accurately 

document patient advance directive 

screening. Provide advance directive 

information when requested, and link 

advance care planning notes to the 

appropriate posting in the electronic 

medical record. 

Quality Management: Track corrective 

actions to completion in meeting 

minutes. Request peer review 

extensions in writing, and obtain facility 

Director approval. Ensure the 

Cardiopulmonary Resuscitation 

Sub-Committee meets quarterly to 

evaluate resuscitation events and 

analyze data. 

Physician Credentialing and Privileging: 

Ensure that the Professional Standards 

Board submits actions and 

recommendations for privileging and 

reprivileging to the Medical Executive 

Board and that board meeting minutes 

include review and decision 

documentation. 

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 Central Arkansas Veterans Healthcare System, Little Rock, AR 

Objectives and Scope
	

Objectives
	

Scope
	

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

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

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following eight activities: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through May 6, 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 Central Arkansas Veterans 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Healthcare System, Little Rock, Arkansas, Report 

No. 08-03042-65, February 4, 2009). The facility had 

corrected all previous findings. (See Appendix B for further 

details.) 

During this review, we also presented crime awareness 

briefings for 424 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. 

Results 

Review Activities With Recommendations 

The purpose of this review was to determine whether the 

facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We identified the following area that needed 

improvement. 

Preparation and Administration. The American Society of 

Health-System Pharmacists specifies the necessary 

personal protective equipment and processes needed for the 

preparation, transport, and administration of chemotherapy 

medications. The pharmacy technician we observed 

preparing an infusion did not clean the chemotherapy gloves 

prior to affixing the label to the infusion bag. Also, pharmacy 

staff improperly attempted to remove the infusion bag from 

the biological safety cabinet before the pharmacy technician 

placed it in a sealable containment bag for transport. 

1. We recommended that processes be strengthened to 

ensure that staff adhere to requirements related to labeling 

chemotherapy infusions and transport. 

Medication 

Management 

Recommendation 

VA OIG Office of Healthcare Inspections 2 
EOC
	

CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

At the Little Rock campus, we inspected medical, surgical, 

intensive care, same day surgery, and post-anesthesia care 

units; the emergency department; and a primary care and 

specialty care clinic. At the North Little Rock campus, we 

inspected a multipurpose inpatient unit, a mental health 

inpatient unit, a community living center dementia inpatient 

unit, a primary care clinic, a mental health clinic, a specialty 

clinic, and the dental clinic. The facility maintained a 

generally clean and safe environment. However, we 

identified the following conditions that needed improvement. 

Medication Security. Joint Commission standards require all 

medications to be secured from access by unauthorized 

persons. In the primary care clinic medication room at the 

North Little Rock campus, we found unsecured stock 

medications. The medication refrigerator was equipped with 

a lock; however, it was open, and staff reported leaving it 

unlocked during the day. The medication cabinet was a wall 

unit that had a pull down door to secure the medications on 

the shelves with a lock. However, the door would neither pull 

down nor lock, leaving stock medications on the shelves 

unsecured. Additionally, the door did not have an automatic 

closure to prevent unintentionally leaving the door open. 

VHA policy requires that access to medication be restricted 

to staff who distribute or administer medication.1 Facility 

policy allowed staff who did not administer or dispense 

medication to enter medication rooms. At the Little Rock 

campus, nursing assistants; health technicians; and Supply, 

Processing, and Distribution technicians were allowed to 

enter the medication room. 

Infection Control. The Occupational Safety and Health 

Administration requires that employees with occupational 

exposure risk receive annual training on the Occupational 

Safety and Health Administration Bloodborne Pathogens 

Rule. We reviewed 37 employee training records and found 

that 31 (84 percent) employees did not have this training 

documented. 

1 VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

If facilities use N95 respirators, the Occupational Safety and 

Health Administration requires that designated employees 

are fit tested annually. We reviewed 15 employee training 

records and determined that 13 designated employees did 

not have the required annual fit testing. 

Patient Privacy. The Health Insurance Portability and 

Accountability Act requires confidential patient information to 

be secured. We found computer screens on two units 

displaying patient information that could be viewed by those 

not using the computer as they passed by. Staff using the 

computers were unaware when someone was standing 

behind them viewing the information. 

Recommendations		 2. We recommended that the facility medication policy be 

revised to be consistent with VHA policy and that processes 

be strengthened to ensure that medication is secured and 

that access to medication is granted only to those who 

distribute or administer medication. 

3. We recommended that processes be strengthened to 

ensure that annual bloodborne pathogens training and 

N95 respirator fit testing are completed and that compliance 

is monitored. 

4. We recommended that processes be strengthened to 

ensure that confidential patient information displayed on 

computer screens is protected from unauthorized access at 

all times. 

Coordination of 

Care 

The purpose of this review was to evaluate whether the 

facility managed advance care planning and advance 

directives in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance directive notification, advance directive screening, 

and documentation of advance care planning discussions. 

We also reviewed the facility’s policy to determine whether it 

was consistent with VHA policy. We identified the following 

areas that needed improvement. 

Advance Directive Notification. VHA requires that patients 

receive written notification at each admission to a VHA 

facility regarding their right to accept or refuse medical 

treatment, to designate a Health Care Agent, and to 

document their treatment preferences in an advance 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

directive.2 As part of notification, patients must be informed 

that VA does not discriminate based on whether or not they 

have an advance directive. We reviewed the medical 

records of 20 patients and found that 4 of the records did not 

contain evidence of all components of written notification. 

Advance Directive Screening Accuracy and Follow-Up. VHA 

requires that staff screen patients at each admission to a 

VHA facility to determine whether they have an advance 

directive and document the screening in the medical record.3 

Although advance directive screenings were completed for 

19 of 20 patients whose medical records we reviewed, 3 of 

the screenings were not accurate regarding the patients’ 

advance directive status. Further, after screening, two 

patients requested additional information about advance 

directives but did not receive any information. 

Advance Care Planning Progress Note Titles. VHA requires 

that staff use specific progress note titles when documenting 

advance care planning discussions with patients and link 

these notes to the Crisis, Warning, Allergies and/or Adverse 

Reactions, and Directives posting in the electronic medical 

record.4 We reviewed documentation for 20 patients and 

determined that 5 records had advance care planning 

documentation. All five records used the appropriate 

progress note titles; however, three of the notes were not 

linked to the Crisis, Warning, Allergies and/or Adverse 

Reactions, and Directives posting. 

Recommendations		 5. We recommended that processes be strengthened to 

ensure that all components of written advance directive 

notification are provided to patients and that notification is 

documented in the medical record. 

6. We recommended that processes be strengthened to 

ensure that patient advance directive screening is accurately 

documented in the medical record and that patients receive 

additional information when it is requested. 

7. We recommended that processes be strengthened to 

ensure that advance care planning notes are linked to the 

Crisis, Warning, Allergies and/or Adverse Reactions, and 

Directives posting. 

2 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 3 VHA Handbook 1004.02.
 4 VHA Handbook 1004.02.
 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

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 areas that needed 

improvement. 

QM Oversight. VHA requires each facility to provide 

oversight to ensure that QM components are implemented, 

integrated, and documented.5 The facility’s Joint Leadership 

Council provides oversight of clinical activities through its 

review of board, committee, and sub-committee minutes; 

however, documentation in different committee meeting 

minutes did not always track corrective actions to 

completion. For example, the MEB recommended a revision 

to the by-laws without assigning a target date for completion, 

and we did not find documentation over the subsequent 

9 months that the action item was completed. 

PR. VHA policy requires facilities to complete a PR within 

120 days.6 Any extension beyond 120 days must be 

requested in writing from and approved by the facility’s 

Director. Neither of the two PRs that exceeded 120 days 

had the required written request and approval for extension. 

Resuscitation and Its Outcomes. VHA requires facilities to 

designate a CPR Committee or equivalent to evaluate 

resuscitation events and analyze data.7 Local policy 

designated the CPR Sub-Committee and required it to meet 

quarterly. The CPR Sub-Committee met only two times 

between March 2010 and April 2011 and last reviewed 

resuscitation events in September 2010. 

Recommendations		 8. We recommended that processes be strengthened to 

ensure that meeting minutes track corrective actions to 

completion. 

5 VHA Directive 2009-043, Quality Management System, September 11, 2009.
 6 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 7 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

9. We recommended that processes be strengthened to 

ensure that PR extensions are requested in writing from and 

approved by the facility’s Director. 

10. We recommended that processes be strengthened to 

ensure that the CPR Sub-Committee meets quarterly to 

evaluate resuscitation events and analyze data. 

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. 

PSB. VHA requires that PSB actions and recommendations 

be submitted to the MEB for review and approval.8 MEB 

meeting minutes did not include documentation of the review 

or approval of PSB privileging or reprivileging 

recommendations prior to granting privileges for the 

15 physicians whose folders we reviewed. 

Recommendation		 11. We recommended that the PSB submit actions and 

recommendations for privileging and reprivileging to the MEB 

and that MEB meeting minutes include documentation of 

reviews and decisions. 

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		

Workplace 

Violence 

The purpose of this review was to determine whether VHA 

facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

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

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

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. 

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

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies, interviewed nurse managers, 

and reviewed initial and ongoing competency assessment 

and validation documents for RNs. We determined that the 

facility had established an effective process to 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 15–22, for the full text of the Directors’ comments.) We consider 

Recommendations 1, 7, 9, 10, and 11 closed. We will follow up on the planned actions 

for the open recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Appendix A 

Facility Profile9 

Type of Organization Tertiary care medical center 

Complexity Level 1A 

VISN 16 

Community Based Outpatient Clinics Conway, AR 

El Dorado, AR 

Hot Springs, AR 

Mena, AR 

Mountain Home, AR 

Pine Bluff, AR 

Russellville, AR 

Searcy, AR 

Veteran Population in Catchment Area Approximately 170,000 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

551 

 Community Living Center/Nursing 

Home Care Unit 

152 

 Other None 

Medical School Affiliation(s) University of Arkansas for Medical Sciences 

 Number of Residents 521 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

May 2011) 

$529.9 

Prior FY (2010) 

$475.5 

 Medical Care Expenditures $338.2 $421.6 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,873 

71,880 

49,873 

1,852 

77,496 

153,829 

o Community Living 

Center/Nursing Home Care Unit 

30,907 35,118 

Hospital Discharges 6,975 11,032 

Total Average Daily Census (including all bed 

types) 

424 422 

Cumulative Occupancy Rate (in percent) 76.0 76.6 

Outpatient Visits 499,456 738,245 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

1. Display suicide prevention posters and 

brochures in highly visible areas throughout 

the facility. 

All areas of both campuses were 

assessed to determine the most 

appropriate areas for posters, 

brochures, and other materials. Staff 

placed materials in areas highly visible 

to patients. Posters are located 

throughout both campuses. Areas are 

checked routinely for restocking. 

Compliance is based on appropriate 

placement of posters 

Y N 

2. Ensure EOC performance measures 

meet VHA standards. 

Policy was revised, and staff track all 

work orders submitted and items that 

need correction to ensure they do not 

exceed 14 days. Items not completed 

within 10 days get referred and must 

be completed within the next 3 days. A 

tracking tool was developed, and 

Engineering reviews it at least weekly. 

Y N 

3. Require local policy to clearly designate 

responsibility for monitoring and maintaining 

the WanderGuard® system, and ensure 

compliance. 

Policy was revised, and staff 

developed a tracking mechanism to 

document WanderGuard® testing. 

Bracelets are tested at least monthly 

when not in use and daily when in use. 

Unit exit door alarms are tested daily. 

Bracelets are tested prior to placement, 

and testing is documented. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Pharmacy Operations and Controlled 

Substances Inspections 

4. Incorporate all responsibilities of the 

Controlled Substance Coordinator into local 

policy. 

Policy was updated on 12/19/08 to 

include all responsibilities. 

Y N 

5. Ensure the vault in the North Little Rock 

outpatient pharmacy is in compliance with 

VA standards and guidelines. 

The correct vault door was installed, 

inspected, and verified to be within VA 

standards and guidelines. 

Y N 

QM 

6. Ensure provider PI data are collected, 

analyzed, reviewed, considered as part of the 

reprivileging process, and recorded in PSB 

minutes. 

The Chief of Staff determined the 

minimum PI data to be collected for 

reprivileging. Each service developed 

a list of PI items to be used for 

reprivileging. A database was 

developed for all services to use. PSB 

minutes now include the PI data used 

during reprivileging. This information is 

documented in the minutes. 

Y N 

7. Ensure designated staff maintain current 

Basic Life Support and/or Advanced Cardiac 

Life Support certifications, in accordance with 

local policy. 

All staff requiring Basic Life Support 

and/or Advanced Cardiac Life Support 

were identified and entered on a 

spreadsheet that is updated when 

training is completed. This data is sent 

to services with staff due to expire 

within 60–120 days. Policy was 

revised to require staff with lapsed 

training to be removed from patient 

care until training is completed. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Medication Management 

8. Require that local policy defines a specific 

timeframe for assessing as needed pain 

medication effectiveness and that responses 

are documented in a timely manner. 

Policy was revised on 4/13/09 to define 

specific timeframes for screening 

patient response to as needed pain 

medications. The policy also requires 

that patient responses are documented 

timely. Monitoring of effectiveness 

documentation is completed monthly. 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

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 67.7 58.0 60.4 57.6 48.7 56.0 52.2 52.6 

VISN 66.1 64.6 63.1 61.8 53.1 54.3 54.6 50.8 

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 13 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

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

conditions10 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 13.25 9.96 15.27 21.71 27.32 17.00 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

10 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 14 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:		 July 15, 2011 

From:		 Director, South Central VA Health Care Network (10N16) 

Subject:		 CAP Review of the Central Arkansas Veterans 

Healthcare System, Little Rock, AR 

To:		 Director, Dallas Office of Healthcare Inspections (54DA) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

1.	 I concur with the recommendations presented in the OIG CAP review 

of the Central Arkansas Veterans Healthcare System. 

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

Mary Jones, HSS, at 601-206-6974. 

(original signed by:) 

George H. Gray, Jr. 

Director, South Central VA Health Care Network (10N16) 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:		 July 13, 2011 

From:		 Director, Central Arkansas Veterans Healthcare System 

(598/00) 

Subject:		 CAP Review of the Central Arkansas Veterans 

Healthcare System, Little Rock, AR 

To:		 Director, South Central VA Health Care Network (10N16) 

I concur with the recommendations presented in the OIG CAP review of 

the central Arkansas Veterans Healthcare System. Actions taken as a 

result of the recommendations can be found in the following pages. 

(original signed by:) 

MICHAEL R. WINN 

Director, Central Arkansas Veterans Healthcare System (598/00) 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

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 

staff adhere to requirements related to labeling chemotherapy infusions and transport. 

Concur 

Target date for completion: Completed June 29, 2011 

All chemotherapy is now prepared within the designated biological safety cabinet 

(biological safety cabinet, aka “chemo hoods”) located on the 6C satellite. Once 

admixture is complete, the preparer uses isopropyl alcohol to surface clean gloves and 

medication bag(s)/vial(s). The medication label is affixed while the preparation remains 

in the biological safety cabinet. The preparation is then placed in the appropriate 

transport bag and bag is sealed BEFORE preparation is removed from the biological 

safety cabinet. All staff responsible for preparing chemotherapy is aware of this 

standard operating procedure. 

Request closure of this recommendation as complete. 

Recommendation 2. We recommended that the facility medication policy be revised to 

be consistent with VHA policy and that processes be strengthened to ensure that 

medication is secured and that access to medication is granted only to those who 

distribute or administer medication. 

Concur 

Target date for completion: April 30, 2012 

MCM 119-2, Medication Management, will be modified by pen and ink change, 

para 4. Procedures, c. Storage (2) to exclude access to medications from the list of 

individuals having access to the medication room. Also, the following statement will be 

added to the same paragraph: only those individuals authorized to distribute or 

administer medications will be allowed access to medications. 

All medications will be secured to allow access only to those individuals who are 

authorized to administer, distribute or dispense medications. Nursing and Pharmacy 

will develop appropriate par levels for medications stocked. Renovations (i.e. new 

cabinets, hasp and lock, band locks, etc.) required to accomplish this measure of 

security will be completed by Engineering Service by April 30, 2012. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Regarding the North Little Rock Employee Health examination room with medications, 

on approximately 8-22-11 the North Little Rock Primary Care Clinic on 3E will be 

moving to 3D. There will be a dedicated area for securing all medications to allow 

access only to those individuals who are authorized to administer, distribute or dispense 

medications. 

Until the move occurs, Associate Nurse Executive (or designee) will: 

1. Insure all staff have been educated on the importance of medication security and 

appropriate procedures for securing all medications. 

2. Perform random weekly monitors to observe that all medications are secured 

(initiated July 8, 2011). 

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

annual bloodborne pathogens training and N95 respirator fit testing are completed and 

that compliance is monitored. 

Concur 

Target date for completion: September 30, 2011 Blood Borne Pathogen 

December 15, 2011 N-95 Fit Testing 

Blood Borne Pathogen: 

A Talent Management System (VA electronic education system—Talent Management 

System) module (#1703756) on blood borne pathogen training has been developed by 

Infection Prevention and Control. A request was sent to Associate Nurse Executive for 

Education and Education Management Committee to assign this module as mandatory 

for all staff has been approved. Infection Prevention and Control will also continue to 

provide face-to-face classes on blood borne pathogens education in New Employee 

Orientation and periodically as needed until the facility meets its goal. Infection 

Prevention and Control will monitor facility compliance weekly and report results to 

facility leadership. Once appropriate compliance level is reached, reports will be 

monitored monthly and reported to facility leadership. This information will also be 

reported to the Infection Prevention and Control Subcommittee. 

N-95 Fit Testing: 

A new SharePoint database (Fit Test) has been developed to document/track 

N-95 respiratory training and fit testing. The database will be reviewed by the 

Engineering Safety Officer and Infection Prevention and Control to insure that all 

appropriate areas are included. All services having employees who need N-95 Fit 

Testing and Training certification will be identified by August 22, 2011. Training and Fit 

testing data currently available in Safety Office files will be transferred to the “Fit Test” 

database by August 30, 2011. The names of current “Fit test" trainers will be shared 

with their individual service. Additional trainers, if needed, will be accomplished by a 

request to the Safety Office no later than September 1, 2011. The comprehensive list of 

staff needing fit testing and training renewals will be compiled and distributed to all 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

service chiefs, supervisors, and facility leadership no later than September 15, 2011. 

The electronic database will be monitored weekly by the Safety Officer with weekly 

reports to facility leadership, with the goal that all required staff is fit tested no later than 

December 15, 2011. Upon reaching the appropriate compliance goal, the Safety Officer 

will provide monthly reports of compliance to facility leadership. 

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

confidential patient information displayed on computer screens is protected from 

unauthorized access at all times. 

Concur 

Target date for completion: April 15, 2012 

The Privacy Officer has conducted an initial assessment/inventory and identified a total 

of 15 computers in public access areas on the inpatient nursing units/wards where 

inappropriate viewing of protected health information might occur. The Privacy Officer 

will work with services to insure that appropriate privacy screens are placed on these 

identified computers no later than October 15, 2011. Privacy screens will be mounted in 

such a manner as to make it difficult, if not impossible to remove them. Environmental 

Assessment Rounds and informal Privacy Officer Rounds will continue to monitor 

compliance of safeguarding patient health information. 

As individuals standing directly behind employees, at the 15 computers identified, may 

still be able to view confidential patient health information, even with privacy screens in 

place, a pilot will be conducted to determine if mirrors could further mitigate the 

identified privacy risk. Mirror(s) will be installed in the pilot area(s) to assist an 

employee's knowledge of anyone approaching or standing behind them no later than 

November 15, 2011. The results of this pilot will be shared with facility leadership no 

later than December 30, 2011. If this pilot proves to be successful, the remaining 

identified areas will have mirrors placed no later than January 15, 2012. 

A second pilot will be conducted to modify one workstation by inlaying the monitor into 

the desk/counter top. If successful, all identified workstations will be modified to further 

mitigate the identified privacy risks for these inpatient ward hallway workstations. 

Pilot is to be completed and results reported to facility leadership no later than 

December 15, 2011. If successful, modifications to other identified workstations to be 

completed no later than April 15, 2012. 

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

all components of written advance directive notification are provided to patients and that 

notification is documented in the medical record. 

Concur 

Target date for completion: September 30, 2011 

VA OIG Office of Healthcare Inspections 19 
 

 

 

CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Nursing Service monitors Admission Assessments on a daily basis. Advance Directive 

notification will be included as a critical component in the monitoring process. This 

information will be made available to Social Work Service and compiled on a quarterly 

basis. Target goal is ≥90 percent compliance. 

Recommendation 6. We recommended that processes be strengthened to ensure that 

patient advance directive screening is accurately documented in the medical record and 

that patients receive additional information when it is requested. 

Concur 

Target date for completion: September 30, 2011 

Nursing Service monitors Admission Assessments on a daily basis. Advance Directive 

notification will be included as a critical component in the monitoring process. This 

information will be made available to Social Work Service and compiled on a quarterly 

basis. Social Work Service will be consulted when a patient requests Advance Directive 

information and/or desires to complete an Advance Directive. During consult 

completion, if appropriate, Social Workers complete the Advance Directive with the 

patient or provide the patient with a packet containing information on completion of an 

Advance Directive with contact information. All Advance Directive consults will be 

monitored to insure that the patient received the additional information requested, as 

evidenced by medical record documentation. Target goal is ≥90 percent compliance. 

Recommendation 7. We recommended that processes be strengthened to ensure that 

advance care planning notes are linked to the Crisis, Warning, Allergies and/or Adverse 

Reactions, and Directives posting. 

Concur 

Target date for completion: June 30, 2011 

Process partially in place, linking Advance Directive planning notes to the Crisis, 

Warning, Allergies and/or Adverse Reactions, and Directives posting, at time of the 

survey. While team on site, change was made to insure that all Advance Directive 

Discussion notes were linked into the Advance Directive planning notes to the Crisis, 

Warning, Allergies and/or Adverse Reactions, and Directives posting. Monitoring of 

50 charts per month will be completed and reported quarterly. Target goal 

is ≥90 percent compliance. 

Request closure of this recommendation as complete. 

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

meeting minutes track corrective actions to completion. 

Concur 

Target date for completion: July 22, 2011 

VA OIG Office of Healthcare Inspections 20 
 

 

CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Mandatory training sessions are being conducted and include all recorders for facility 

level committees, boards, and council. These sessions cover appropriate minutes 

format (issue, discussion, action, responsibility person, target date), along with 

processes for tracking items to closure, and use of an audit tool to assist in assurance 

of closing the loop on corrective actions. To date, 31 of 38 required individuals 

(84 percent) have received the training. Final training sessions are scheduled for 

July 19 and 22, 2011 to complete the final 7 required attendees. 

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

PR extensions are requested in writing from and approved by the facility’s Director. 

Concur 

Target date for completion: July 1, 2011 

Of the 631 cases reviewed for FY10, only 2 (0.003 percent) were not completed 

in ≤120 days. Days elapsed for PRs are being tracked and shared at each PR 

Committee meeting. Cases beyond 80 days will be closed by the next scheduled PR 

Committee meeting in order to prevent reaching the 120 day limit prior to a meeting. 

Any cases reaching ≥120 days prior to the next scheduled PR Committee meeting will 

have an approved request for extension by the Director. Quarterly monitors for the 

specific element of PRs extending beyond the 120 day limit, with the written approval of 

the Medical Center Director, will begin FY11Q4. 

Request this recommendation be closed as complete. 

Recommendation 10. We recommended that processes be strengthened to ensure 

that the CPR Sub-Committee meets quarterly to evaluate resuscitation events and 

analyze data. 

Concur 

Target date for completion: May 24, 2011 

The CPR Subcommittee has a newly assigned chair. The subcommittee met on 

5/24/11 and changed their process to scheduling meetings monthly which will insure 

meetings occur at least quarterly as stated in policy. Each resuscitation occurrence is 

initially evaluated and analyzed by a QM Coordinator. All outliers are then forwarded to 

the Resuscitation Event Advisory Group for in-depth review, analysis, and consideration 

for potential PR. Information from the QM Coordinator and Resuscitation Event 

Advisory Group is then reviewed/analyzed/trended by the CPR Subcommittee. All 

resuscitation events not previously evaluated were completed at the 5/24/11 meeting. 

Request this recommendation be closed as complete. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Recommendation 11. We recommended that the PSB submit actions and 

recommendations for privileging and reprivileging to the MEB and that MEB meeting 

minutes include documentation of reviews and decisions. 

Concur 

Target date for completion: July 12, 2011 

PSB recommendations were voted on at the MEB immediately following the PSB 

meeting (MEB meets immediately after PSB) so as not to delay any actions taken. PSB 

actions has been added as a standing agenda item for the MEB meeting beginning with 

the July 12th meeting, thereby insuring documentation of reviews and voting by the 

entire MEB prior to forwarding to the Medical Center Director. 

Request this recommendation be closed as complete. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

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 Cathleen King, CRRN, MHA, Project Leader 

Gayle Karamanos, PA-C, Team Leader 

Larry Ross, MS 

Maureen Washburn, RN 

Misti Kincaid, BS, Program Support Assistant 

Tom Godeaux, Resident Agent in Charge, Office of Investigations 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the Central Arkansas Veterans Healthcare System, Little Rock, AR 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, South Central VA Health Care Network (10N16) 

Director, Central Arkansas Veterans Healthcare System (598/00) 

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 Boozman, Mark L. Pryor 

U.S. House of Representatives: Rick Crawford, Tim Griffin, Mike Ross 

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

VA OIG Office of Healthcare Inspections 24