Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-00030-160 

Combined Assessment Program
 

Review of the
 

Tennessee Valley Healthcare System
 

Nashville, Tennessee
 

May 5, 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 Tennessee Valley Healthcare System, Nashville, TN 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CLC community living center 

COC coordination of care 

CPR cardiopulmonary resuscitation 

ED emergency department 

EOC environment of care 

facility Tennessee Valley Healthcare System 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

IC infection control 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MEB Medical Executive Board 

MH mental health 

MRSA Methicillin-resistant Staphylococcus Aureus 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PET/CT positron emission tomography/computed tomography 

PRC Peer Review Committee 

QM quality management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Table of Contents
 

Page
 

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

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

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

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

Reported Accomplishment........................................................................................ 2
 

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

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

EOC................................................................................................................... 2
 

QM..................................................................................................................... 4
 

Physician C&P................................................................................................... 5
 

Management of MDRO...................................................................................... 5
 

Management of Test Results............................................................................. 6
 

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

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

Medication Management ................................................................................... 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................ 10
 

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 18
 

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

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

Review of the Tennessee Valley Healthcare System,
 

Nashville, TN
 

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 

March 7, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

 Coordination of Care 

 Medication Management 

The facility’s reported accomplishment 

was the development of a tri-fold 

brochure that identifies the best 

treatment for elimination of specific 

infections and the associated cost. The 

brochure is distributed annually to all 

medical providers. 

Recommendations: We made 

recommendations in the following five 

activities: 

Environment of Care: Require that fire 

extinguishers and exits are clear of 

obstructions. Ensure that portable 

oxygen tanks are secured and that 

environmental hazards on the locked 

mental health units are corrected. 

Require that annual bloodborne 

pathogens training and respirator fit 

testing is completed and documented. 

Quality Management: Ensure that the 

Cardiopulmonary Resuscitation 

Committee meets monthly, evaluates 

resuscitation events, analyzes data, and 

identifies opportunities to improve 

processes. Require that the Peer 

Review Committee trends and analyzes 

peer review results and reports all 

required elements to the Medical 

Executive Board quarterly. 

Physician Credentialing and Privileging: 

Ensure that Focused Professional 

Practice Evaluations are defined, 

approved, and documented for all 

physicians who have been newly hired 

or have added new privileges. 

Management of Multidrug-Resistant 

Organisms: Ensure that employees 

receive annual education and that the 

training is consistently documented. 

Management of Test Results: Ensure 

that normal test results are consistently 

communicated to patients within the 

specified timeframe. 

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 Tennessee Valley Healthcare System, Nashville, TN 

Objectives and Scope
 

Objectives
 

Scope
 

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

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

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through March 7, 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 Tennessee Valley 

Healthcare System, Nashville, Tennessee, Report 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

No. 08-01446-93, March 10, 2009). (See Appendix B for 

further details.) The facility had a repeat finding in the area 

of QM. 

During this review, we also presented crime awareness 

briefings for 124 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 Accomplishment
 Antibiogram	 The facility’s medical media department produced an 

antibiogram1 tri-fold brochure for the microbiology 

department in response to a College of American 

Pathologists recommendation. The brochure identifies the 

best treatment for elimination of specific organisms and the 

associated cost. It also includes current isolation guidelines, 

discontinuation criteria for isolation, and surveillance 

screening for MRSA. The brochure is campus specific, and 

the data comes from the computerized laboratory package 

that counts the organisms isolated, the antibiotics tested, and 

the percent susceptible to the antibiotic. The brochure is 

distributed annually to all medical providers and to other staff 

as appropriate. 

Results 

Review Activities With Recommendations 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

At the Nashville campus, we inspected the inpatient acute 

medicine (2N), acute medicine/palliative care (2G), and 

acute medicine/surgery (3N) units; the locked MH unit (4BN); 

the gastroenterology, bronchoscopy, and cardiac 

catheterization laboratories; the surgical intensive care unit; 

the podiatry and primary care clinics; and the ED. We also 

1 An antibiogram is the result of a laboratory test for the sensitivity of an isolated bacterial strain to different 

antibiotics. http://www.websters-online-dictionary.org, accessed on March 23, 2011. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

inspected the ultrasound, computed tomography, and 

interventional and general radiology areas. 

At the Murfreesboro campus, we inspected the inpatient 

acute medicine (1A) unit, the locked MH units (7A and 7B), 

the gastroenterology laboratory, the CLC units (8A, 8B, 9B, 

East, and West), the medical intensive care unit, primary 

care clinics (A and C), and the ED. We also inspected 

PET/CT and general radiology areas. 

The facility maintained a generally clean and safe 

environment. However, we identified the following areas at 

both campuses that needed improvement. 

Fire and Safety. The JC requires that fire extinguishers and 

exits be clear of obstructions. We found multiple areas 

where fire extinguishers and exits were blocked by medical 

equipment, biohazard waste containers, and waiting room 

furniture. 

Environmental Safety. OSHA requires that portable oxygen 

tanks be secured. We found unsecured portable oxygen 

tanks in multiple areas. 

VHA requires a safe environment for all patients in inpatient 

MH programs.2 We found the following environmental 

hazards on the locked MH units: (a) plastic picture frames in 

sally ports (secured controlled entryways), (b) a shred box in 

one sally port, (c) rolling bedside tables in patient rooms, and 

(d) plastic trash bags on unsecured housekeeping carts.3 

IC. OSHA requires that all employees receive initial and 

annual training on the OSHA Bloodborne Pathogens Rule. 

We reviewed 37 employee training records and found that 

only five (14 percent) employees had this training 

documented. 

If facilities use N95 respirators, OSHA requires that 

designated employees are fit tested annually. We reviewed 

48 employee training records and found that only 

31 (65 percent) employees had the required annual fit 

testing. 

2 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics,
 

September 11, 2008.

3 VA National Center for Patient Safety, “Mental Health Environment of Care Checklist,” November 1, 2010.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Recommendations 

QM
 

1. We recommended that processes be strengthened to 

ensure that fire extinguishers and exits are clear of 

obstructions. 

2. We recommended that processes be strengthened to 

ensure that portable oxygen tanks are secured. 

3. We recommended that environmental hazards on the 

locked MH units be corrected. 

4. We recommended that annual bloodborne pathogens 

training and respirator fit testing be completed and 

documented. 

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. 

Resuscitation and Its Outcomes. VHA requires facilities to 

evaluate resuscitation events and analyze data.4 Local 

policy requires that the CPR Committee meet monthly. CPR 

committee minutes did not reflect discussions related to 

resuscitation events or data analysis and did not identify 

opportunities to improve CPR processes. In addition, the 

committee met only six times between January 2010 and 

February 2011. 

Peer Review. VHA requires that peer review results be 

trended and analyzed and that the data be reported to the 

MEB on a quarterly basis.5 We found that the PRC did not 

trend and analyze peer review results or adequately report to 

the MEB. This was a repeat finding from the previous CAP 

review. During FY 2010, the PRC only reported to the MEB 

for 3 of the 4 quarters, and the reports did not include all 

required elements. 

4 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 5 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Recommendations 

Physician C&P 

Recommendation 

Management of 

MDRO 

5. We recommended that the CPR Committee meet 

monthly, evaluate resuscitation events, analyze data, and 

identify opportunities to improve CPR processes. 

6. We recommended that the PRC trend and analyze peer 

review results and report all required elements to the MEB 

quarterly. 

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 10 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 a defined and approved FPPE be 

initiated and documented for all physicians who have been 

newly hired or have added new privileges.6 We reviewed the 

profiles for two newly hired physicians. We found that while 

FPPEs had been initiated, criteria were not defined or 

approved. In addition, FPPEs were not documented in MEB 

minutes. 

7. We recommended that FPPEs be defined, approved, 

and documented for all physicians who have been newly 

hired or have added new privileges. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

At the Nashville campus, we inspected the acute medicine 

(2N) and acute medicine/surgery (3N) units. At the 

Murfreesboro campus, we inspected the CLC East and 9B 

units. Additionally, we interviewed employees. We did not 

identify any deficits in either the inspections or staff 

interviews. However, we identified the following area that 

needed improvement. 

Employee Training. The JC requires that facilities conduct 

an IC risk assessment to determine the need for staff 

education on MDRO. The facility’s most recent risk 

assessment stated that staff education was indicated for all 

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

employees during orientation and annually thereafter. We 

reviewed 37 employee training records to determine whether 

MDRO education had been provided in accordance with the 

risk assessment. We found that only five (14 percent) of the 

records reviewed had documentation of annual MDRO 

education. 

Recommendation	 8. We recommended that employees receive annual 

MDRO education and that the training is consistently 

documented. 

Management of	 The purpose of this review was to follow up on a previous 

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.7 

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following area 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.8 We reviewed the medical 

records of 20 outpatients who had normal results and found 

that only 11 of the 20 records contained documented 

evidence that the facility had communicated the results to the 

patients within the specified timeframe. 

Recommendation	 9. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

Review Activities Without Recommendations
 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records and determined that 

the facility generally met requirements in these areas. We 

made no recommendations. 

7 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 8 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Medication 

Management 

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 determined that the facility safely prepared, 

transported, and administered the medications. We made no 

recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

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

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix A 

Facility Profile9 

Type of Organization Tertiary care integrated medical center 

Complexity Level 1A 

VISN 9 

Community Based Outpatient Clinics Chattanooga, TN 

Tullahoma, TN 

McMinnville, TN 

Cookeville, TN 

Rockwood, TN 

Clarksville, TN 

Ft. Campbell, TN 

Bowling Green, TN 

Hopkinsville, TN 

Dover, TN 

Veteran Population in Catchment Area 302,795 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

255 

 CLC/Nursing Home Care Unit 238 

 Other None 

Medical School Affiliation(s) Vanderbilt University 

Meharry Medical College 

 Number of Residents 695 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

March 2011) 

$594 

Prior FY (2010) 

$598 

 Medical Care Expenditures $175 $598 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

3,221 

53,579 

9,523 

3,224 

80,825 

37,125 

o CLC/Nursing Home Care Unit 18,412 72,574 

Hospital Discharges 2,883 10,472 

Total Average Daily Census (including all bed 

types) 

393.9 388.2 

Cumulative Occupancy Rate (in percent) 80.5 78.9 

Outpatient Visits 151,444 786,459 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure QM experts complete a 

comprehensive review of the QM 

Department to redesign the processes used 

to capture, trend, analyze, document, 

correct, and follow up required QM activities. 

Progress has been made with 

restructuring of committees, 

standardization of minutes, 

standardization of tracking logs, and 

structuring of agenda (Quality 

Executive Board grid), which 

addresses QM items that should be 

tracked. 

N Y (See pages 4–5) 

Emergency/Urgent Care Operations 

2. Ensure all ED registered nurse 

competency folders are updated and 

maintained in accordance with local policy. 

All ED competency folders are 

reviewed during the annual 

performance evaluation period. One 

hundred percent of the folders are in 

compliance. 

Y N 

Medication Management 

3. Consistently document pain medication 

effectiveness within the required timeframe. 

Pain medication effectiveness 

documentation is reported to the Bar 

Code Medication Administration 

Committee. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

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 58.4 57.8 67.6 60.3 54.4 51.0 49.6 50.7 

VISN 62.2 61.2 63.4 62.5 55.5 56.5 54.4 54.7 

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. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

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 CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 12.61 10.28 15.45 18.28 20.07 15.46 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

10 Congestive heart failure (CHF) is a weakening of the heart’s pumping power. With heart failure, your body does 

not get enough oxygen and nutrients to meet its needs. A heart attack (also called acute myocardial infarction) 

happens when blood flow to a section of the heart muscle becomes blocked and the blood supply is slowed or 

stopped. If the blood flow is not restored in a timely manner, the heart muscle becomes damaged from lack of 

oxygen. Pneumonia is a serious lung infection that fills your lungs with mucus and causes difficulty breathing, 

fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 April 25, 2011 

From:	 Network Director (10N9), VA Mid South Healthcare Network 

Subject:	 CAP Review of the Tennessee Valley Healthcare System, 

Nashville, TN 

To:	 Director, Atlanta Office of Healthcare Inspections (54AT) 

Director, Management Review Service (VHA CO 10B5 Staff) 

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

the Tennessee Valley Healthcare System site visit that was conducted the 

week of March 7, 2011. We concur with the recommendations, and will 

ensure completion as described in the attached plan by the established 

target dates. 

2. If you have any questions regarding the attached response or action for 

recommendations please contact Ms. Tammy K. Williams, VISN 9 

Continuous Readiness Officer, VISN 9 at 615-695-2143. 

(original signed by:) 

John Dandridge, Jr. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 April 21, 2011 

From:	 Director (626/00), Tennessee Valley Healthcare System 

Subject:	 CAP Review of the Tennessee Valley Healthcare System, 

Nashville, TN 

To:	 Director, VA Mid South Healthcare Network (10N9) 

1. VA Tennessee Valley Healthcare System appreciates the opportunity 

to review the OIG report on the CAP Review of the Tennessee Valley 

Healthcare System, Nashville, TN. 

2. Please find attached our response to each recommendation provided 

in the report. 

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

recommendations in the report or if there is any additional information 

required, you may contact Mr. Paul Crews, Chief, Quality Management 

Services at 615-873-7080. 

(original signed by:) 

Juan A. Morales, RN, MSN 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

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 

fire extinguishers and exits are clear of obstructions. 

Concur 

Action Completed: March 10, 2011 

1.	 Obstructions were removed that prevented access to fire safety equipment and 

exits. 

2.	 TVHCS staff were re-educated on the requirement not to obstruct fire safety 

equipment and exits. 

3.	 Weekly Environmental rounds will monitor for continued compliance. 

4.	 The Environment of Care Committee will review significant outstanding issues 

quarterly or sooner as appropriate. 

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

portable oxygen tanks are secured. 

Concur 

Action Completed: March 10, 2011 

1.	 All portable oxygen tanks were secured. 

2.	 TVHCS staff were re-educated on the requirement and proper procedure for 

securing portable oxygen tanks. 

3.	 Weekly environmental rounds will monitor for continued compliance. 

4.	 The Environment of Care Committee will review significant outstanding issues 

quarterly or sooner as appropriate. 

Recommendation 3. We recommended that environmental hazards on the locked MH 

units be corrected. 

Concur 

Action Completed: April 8, 2011 

1.	 Environmental hazards were removed at the time of inspection. 

2.	 Shred Ahead box relocated. 

3.	 Weekly environmental rounds will monitor for continued compliance. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

4.	 The Environment of Care Committee will review significant outstanding issues 

quarterly or sooner as appropriate. 

Recommendation 4. We recommended that annual bloodborne pathogens training 

and respirator fit testing be completed and documented. 

Concur 

Target date for completion: September 30, 2011 

1.	 Executive leadership will re-emphasize compliance with annual requirements for 

blood borne pathogens training and respirator fit testing to all Service Chiefs. 

2.	 Compliance with training requirements will be included in the employee annual 

performance review. 

3.	 Compliance with annual infection control training will be reported quarterly to the 

Infection Control Committee. 

4.	 Process for identification of employees requiring fit testing is under revision. New 

process will involve identification of anyone who has a job related function within 

airborne isolation areas. All staff will be medically evaluated for fit testing prior to 

initial performance of their functions. 

5.	 Vanderbilt University Medical Center fit testing will be accepted, when 

appropriately documented, for those employees who work in both hospitals. 

6.	 Additional approved respirator styles will be offered to Vanderbilt employees 

tested using another mask. 

7.	 A schedule for fit testing will be posted in employee areas. 

Recommendation 5. We recommended that the CPR Committee meet monthly, 

evaluate resuscitation events, analyze data, and identify opportunities to improve CPR 

processes. 

Concur 

Target date for completion: September 30, 2011 

1.	 The CPR Committee will meet monthly. 

2.	 The data collection form for resuscitative events has been revised and utilizes 

information from the American Heart Association. 

3.	 Performance goals have been developed to assist in developing performance 

improvement plans. 

4.	 Clinical Nurse Leaders and Nurse Managers will review code sheets prior to 

submission to Quality Management Service and Critical Care Educator. 

5.	 Critical Care Educator will trend and analyze data for reporting to the CPR 

Committee monthly. 

6.	 Quality Management Specialist is assigned to the CPR Committee for assistance 

with data gathering, trending and analysis. 

7.	 Joint Commission Consultant is scheduled to provide a presentation on effective 

documentation and data gathering, trending and analysis on April 27, 2011. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Recommendation 6. We recommended that the PRC trend and analyze peer review 

results and report all required elements to the MEB quarterly. 

Concur 

Action Completed: April 19, 2011 

1.	 A report has been generated for FY10 with multiple graphs trending the initial 

levels of Peer Review, final levels of Peer Review, all changes made by the Peer 

Review Committee and the numbers of Peer Reviews that the Committee did not 

change for these four quarters. 

2.	 This information was presented at the April MEB meeting. 

3.	 This report will be placed on the agenda quarterly and included in the MEB 

minutes. 

Recommendation 7. We recommended that FPPEs be defined, approved, and 

documented for all physicians who have been newly hired or have added new 

privileges. 

Concur 

Action Completed: March 14, 2011 

As of March 14, 2011, the minutes of the PSB/MEB will include documentation of initial 

FPPE as follows: 

	 The FPPE will be completed once the provider officially comes on board. The 

evaluation will include a review of 10 charts per month for a period of 

3 months (depending on the requirement for those particular privileges). 

 The final report will be forwarded to the medical Staff Office for presentation
 

to the Professional Standards Board/Medical Executive Board (PSB/MEB).
 

 The minutes of the PSB/MEB will be reviewed and approved by the Director
 

and this will serve as initial notification. 

 The completion of the FPPE will be expanded in the PSB/MEB minutes to 

include the results. 

 The Medical Staff Office will monitor compliance. 

Recommendation 8. We recommended that employees receive annual MDRO 

education and that the training is consistently documented. 

Concur 

Target date for completion: September 30, 2011 

1.	 Executive leadership will re-emphasize compliance with annual requirements for 

annual infection control training to all Service Chiefs. 

2.	 Compliance with training requirements will be included in the employee annual 

performance review. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

3.	 Compliance with annual infection control training will be reported quarterly to the 

Infection Control Committee. 

Recommendation 9. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: May 1, 2011 

1.	 The Chief of Staff office has sent a notice to all Clinical Service Chiefs directing 

them to communicate with their providers at the next staff meeting regarding the 

importance of communicating test results, including normal values, to their 

patients. 

2.	 Information disseminated no later than April 22, 2011. 

3.	 The Chief of Staff office will provide follow up to ensure all Service Chiefs have 

communicated with their providers. 

4.	 Compliance will be monitored through record reviews for communication of 

normal lab values within 14 days. 

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CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

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 Tishanna McCutchen, NP, Team Leader 

Nancy Albaladejo, RN 

Karen Sutton, BS 

Toni Woodard 

Susan Zarter, RN 

Brian Celatka, Special Agent, Office of Investigations 

Richard Ellison, Special Agent, Office of Investigations 

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CAP Review of the Tennessee Valley Healthcare System, Nashville, TN 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid South Healthcare Network (10N9) 

Director, Tennessee Valley Healthcare System (626/00) 

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: Lamar Alexander, Bob Corker 

U.S. House of Representatives: Diane Black, Jim Cooper 

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

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