Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01606-277 

Combined Assessment Program
 

Review of the
 

St. Louis VA Medical Center
 

St. Louis, Missouri
 

September 13, 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 St. Louis VA Medical Center, St. Louis, MO 

Glossary 

AD advance directive 

C&P credentialing and privileging 

CAP Combined Assessment Program 

EN enteral nutrition 

EOC environment of care 

facility St. Louis VA Medical Center 

FY fiscal year 

IC infection control 

MH mental health 

OIG Office of Inspector General 

PR peer review 

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 St. Louis VA Medical Center, St. Louis, MO 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

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

Coordination of Care ......................................................................................... 3
 

EN Safety .......................................................................................................... 4
 

RN Competencies ............................................................................................. 6
 

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

EOC................................................................................................................... 7
 

Review Activity Without Recommendations............................................................ 8
 

Medication Management ................................................................................... 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................ 15
 

D. VISN Director Comments .................................................................................. 17
 

E. Facility Director Comments ............................................................................... 18
 

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 St. Louis VA Medical Center,
 

St. Louis, MO
 

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 

June 13, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activity: 

 Medication Management 

Recommendations: We made 

recommendations in the following seven 

activities: 

Quality Management: Analyze 

aggregate data, document discussions, 

and make recommendations based on 

the analysis. Require written requests 

for peer review extensions to be 

submitted to the facility Director and 

approved in writing prior to the 120-day 

deadline. 

Physician Credentialing and Privileging: 

Ensure physicians complete the 

required training regarding medications 

used for moderate sedation. 

Coordination of Care: Update facility 

advance directive policy to define staff 

responsibilities, and ensure all 

components of notification and 

screening are provided and documented 

in the medical record. 

Enteral Nutrition Safety: Revise facility 

enteral nutrition and infection control 

policies, and monitor compliance with 

the updated policies. Ensure enteral 

nutrition documentation includes all 

required elements. Provide written 

instructions to patients discharged with 

enteral nutrition, and document receipt. 

Registered Nurse Competencies: 

Consistently follow the established 

process for competency assessment 

and validation, identify competencies 

that are consistent with individual 

nursing assignments, ensure 

competency validation documentation is 

complete, and specify the methods used 

to assess and validate competency. 

Management of Workplace Violence: 

Write and implement a comprehensive 

workplace violence policy that includes 

a training plan. 

Environment of Care: Ensure 

designated staff complete annual 

N95 respirator fit testing, and monitor 

compliance. 

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 St. Louis VA Medical Center, St. Louis, MO 

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 June 17, 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 St. Louis VA Medical 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Center, St. Louis, Missouri, Report No. 08-00400-190, 

August 26, 2008). (See Appendix B for further details.) The 

facility had corrected 18 of the 20 findings from our previous 

review. 

During this review, we also presented crime awareness 

briefings for 38 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 

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. 

Data Analysis. VHA requires that facilities review and 

analyze QM data, take actions based on the analysis, and 

track actions to completion.1 Committees responsible for 

oversight of moderate sedation, mortality review, and 

resuscitation events did not analyze aggregate QM data. 

Although committee minutes documented discussion of 

individual patient events with aggregate data attached to the 

minutes, there was no documentation of review, discussion, 

or analysis of the aggregate data. The critical analysis of 

aggregate moderate sedation data was a repeat finding from 

the previous CAP review. 

PR. VHA requires that PRs be completed within 120 days 

and that any needed extensions be requested in writing from 

and approved by the facility Director.2 During FY 2011, 

36 reviews exceeded the 120-day timeframe, and extensions 

1 VHA Directive 2009-043, Quality Management System, September 11, 2009. 2 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Recommendations 

Physician C&P 

Recommendation 

Coordination of 

Care 

were not properly requested. The process for written 

requests for extensions was implemented the week before 

our review. Meeting timeliness requirements for PRs was a 

repeat finding from the previous CAP review. 

1. We recommended that committees responsible for 

moderate sedation, mortality review, and resuscitation 

events analyze aggregate QM data, document their 

discussion, and make recommendations based on the 

analysis. 

2. We recommended that written requests for PR 

extensions be submitted to the facility Director and approved 

in writing prior to the 120-day deadline. 

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 17 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. 

Ongoing Professional Practice Evaluation. Facility policy 

requires that providers who administer moderate sedation 

complete training regarding medications used for sedation. 

None of the four physician profiles or training records we 

reviewed for moderate sedation competency had evidence of 

the locally required training. 

3. We recommended that physicians complete the required 

training regarding medications used for moderate sedation. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning and ADs in 

accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of AD 

notification, AD screening, and documentation of advance 

care planning discussions. We also reviewed the facility’s 

policy to determine whether it was consistent with VHA 

policy. We identified the following areas that needed 

improvement. 

AD Notification and Screening. VHA requires that patients 

receive written notification at each admission to a VHA 

facility regarding their right to accept or refuse medical 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

treatment, to designate a Health Care Agent, and to 

document their treatment preferences in an AD.3 As part of 

notification, patients must be informed that VA does not 

discriminate based on whether or not they have an AD. We 

reviewed the medical records of 20 patients and found that 

none of the records contained evidence of all required 

components of written notification. 

Additionally, VHA requires that staff screen patients at each 

admission to a VHA facility to determine whether they have 

an AD and document the screening in the medical record.4 

Facility staff did not document all the components of AD 

screening for 8 of the 20 patients whose medical records we 

reviewed. 

Facility Policy. VHA requires that the facility identify the staff 

responsible for providing AD notification.5 Facility policy did 

not designate the staff responsible for providing AD 

notification. 

Recommendations	 4. We recommended that processes be strengthened to 

ensure that all components of written AD notification and 

screening are provided to patients and documented in the 

medical record. 

5. We recommended that facility policy be updated to 

include identification of the staff responsible for providing AD 

notification. 

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. We also inspected areas where 

EN products were stored while conducting the EOC review, 

and we interviewed key employees. We identified the 

following areas that needed improvement. 

Policy. VHA requires that health care staff follow specific 

procedures relating to EN.6 Three of four local policies had 

not been updated and were inconsistent with current VHA 

policy. For example, VHA requires x-ray confirmation of 

3 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 4 VHA Handbook 1004.02.
 5 VHA Handbook 1004.02.
 6 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007.
 

VA OIG Office of Healthcare Inspections 4 
Recommendations 

CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

nasogastric tube placement prior to using the tube for EN 

feedings. However, one local policy required x-ray 

verification of tube placement only if certain bedside tests did 

not confirm proper tube placement. 

VHA also requires that facility IC policy address EN.7 We 

reviewed facility IC policy and determined that it did not 

address IC expectations for EN, such as swabbing the tops 

of EN cans with alcohol wipes before pouring contents into 

feeding bags. 

EN Documentation. VHA requires that staff document 

specific EN information in patients’ medical records.8 We 

reviewed the medical records of 10 EN patients and found 

that 7 records did not contain all required information, such 

as x-ray verification of nasogastric tube placement prior to 

using the tube for EN feedings, checking gastric residual, or 

positioning the patient. 

EN Patient Education. VHA requires that patients receive 

instructions regarding diet upon discharge.9 In addition, The 

Joint Commission requires that clinicians provide patients 

with written discharge instructions and document that the 

instructions were received. We reviewed the medical 

records of three EN patients and found that two records did 

not contain documentation that EN discharge instructions 

were provided. 

6. We recommended that facility policies related to EN be 

updated to be consistent with VHA policy, that facility IC 

policy be revised to include EN IC expectations, and that 

compliance with the updated policies be monitored. 

7. We recommended that processes be strengthened to 

ensure that EN documentation includes all required 

elements. 

8. We recommended that processes be strengthened to 

ensure that written instructions are provided to patients 

discharged with EN and that receipt is documented. 

7 VHA Handbook 1109.05. 

8 VHA Handbook 1109.05. 

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

RN Competencies
 

Recommendations 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility standard operating procedures, 

interviewed nurse managers, and reviewed initial and 

ongoing competency assessment and validation documents 

for 12 RNs. We identified the following areas that needed 

improvement. 

Facility Competency Validation Process. The Joint 

Commission requires that clinical staff are deemed 

competent to perform their job responsibilities and that the 

facility takes action when staff competency does not meet 

expectations. A competency validation policy or process is 

required for staff who provide patient care, treatment, or 

services. Although the facility had implemented a 

competency validation process in the month prior to our 

review, the process was not evident for 9 of the 12 RNs. 

Competency Validation Documentation. The Joint 

Commission requires that nursing personnel are competent 

to function in their assignments. Core competencies, such 

as medication administration, are skills required for all RNs. 

Unit/position competencies are specific to a particular area of 

patient care, such as an intensive care unit. Ten of the 

12 RN competency folders had incomplete or missing 

unit-specific competencies for FY 2010. 

Competency Validation Methods. The Joint Commission 

requires facilities to specify the assessment methods used 

(such as test taking, demonstration, or simulation) to 

determine an individual’s competency in required skills. In 

9 of the 12 competency folders, we found that validation 

methods were not specified for the skills being assessed and 

validated. 

9. We recommended that the established process for initial 

and ongoing RN competency assessment and validation be 

consistently followed. 

10. We recommended that managers identify 

unit/position-specific RN competencies for all patient care 

areas that are consistent with the individual’s nursing 

assignment. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Management of 

Workplace 

Violence 

Recommendation 

EOC 

11. We recommended that processes be strengthened to 

ensure that competency validation documentation is 

complete. 

12. We recommended that unit/position-specific competency 

validation documentation specify the methods used to 

assess and validate competency. 

The purpose of this review was to determine whether VHA 

facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. 

We interviewed managers and reviewed applicable 

documents. We identified the following area that needed 

improvement. 

Facility Policy. The Occupational Safety and Health 

Administration requires facilities to have a comprehensive 

written workplace violence policy. The facility did not have a 

policy, training plan, or process in place that addressed 

managing violent or disruptive behavior. 

13. We recommended that a comprehensive workplace 

violence policy that includes a training plan be written and 

implemented. 

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 inpatient units (medical, surgical, telemetry, 

intensive care, progressive care, MH, rehabilitation, spinal 

cord injury, and community living center), the emergency 

department, the same day surgery/post-anesthesia care unit, 

and outpatient clinics. The facility maintained a generally 

clean and safe environment. However, we identified the 

following condition that needed improvement. 

IC. If facilities use N95 respirators, the Occupational Safety 

and Health Administration requires that designated 

employees are fit tested annually. We reviewed 

25 employee training records and determined that 

4 designated employees did not have the required annual fit 

testing. 

14. We recommended that annual N95 respirator fit testing 

be completed and that compliance be monitored. 

Recommendation 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Review Activity Without Recommendations
 

Medication 

Management 

The purpose of this review was to determine whether the 

facility employed safe practices in the preparation, 

transportation, and administration of hazardous medications, 

specifically chemotherapy, in accordance with applicable 

requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the pharmacy and the chemotherapy clinic. 

We also interviewed staff. 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 17–22 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 8 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Appendix A 

Facility Profile10 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 15 

Community Based Outpatient Clinics Belleville, IL 

St. Louis, MO 

St. Charles, MO 

Veteran Population in Catchment Area 239,016 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

285 

 Community Living Center/Nursing 

Home Care Unit 

71 

 Other 0 

Medical School Affiliation(s) Saint Louis University School of Medicine 

Washington University School of Medicine 

 Number of Residents 126.5 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

April 2011) 

$357 

Prior FY (2010) 

$367 

 Medical Care Expenditures $211 $367 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

2,429 

47,371 

47,723 

2,330.1 

47,203 

45,535 

o Community Living 

Center/Nursing Home Care Unit 

12,117 11,552 

Hospital Discharges 6,218 6,089 

Total Average Daily Census (including all bed 

types) 

282.75 269.28 

Cumulative Occupancy Rate (in percent) 79.42 75.64 

Outpatient Visits 356,407 376,468 

10 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations 

QM 

Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

1. Use performance data in the C&P N

process, in accordance with VHA policy. 

Standardized Ongoing Professional Practice 

Monitor Reports are in place. The Medical 

Staff Improvement Plan is updated annually. 

Y 

2. Meet VHA requirements for 

cardiopulmonary resuscitation training for all 

clinically active staff. 

Facility policy was revised to include all 

clinically active staff. The Code K Committee 

and service chiefs monitor compliance. 

Y N 

3. Privilege contracted providers only for the 

time they are associated with the facility. 

Contracted providers are privileged only for 

the period of their appointment (January to 

December each year). 

Y N 

4. Meet VHA timeliness requirements for 

PRs. 

PR timeliness is monitored by the Risk 

Manager; reminders are sent to providers and 

service chiefs. Additional PR Committee 

meetings are held. Screening criteria was 

developed and approved to decrease the 

number of PRs sent to committee. 

N Y (see pages 2–3) 

5. Meet VHA requirements for inter-rater 

reliability reviews for the utilization 

management program. 

Inter-rater reliability is monitored by the 

utilization management coordinator. Testing 

is current. 

Y N 

6. Meet VHA requirements for copying and 

pasting text into the electronic medical 

record. 

Chief Health Information Management 

established facility policy governing copying 

and pasting. A process was established for 

staff to report copy and paste occurrences. 

Medical records are monitored. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

7. Critically analyze, trend, and monitor 

aggregate moderate sedation data. 

Moderate sedation is tracked and analyzed 

by the Invasive Procedure Committee. In 

2011, oversight responsibility was changed to 

the Medical Staff Performance Improvement 

Committee. 

N Y (see pages 2–3) 

8. Complete operative reports in 

accordance with VHA policy. 

The Chief and Assistant Chief of Surgery 

Service continue to monitor completion of 

operative reports. Compliance is currently at 

99.4 percent. 

Y N 

9. Address patient flow in temporary bed 

and overflow locations. 

Policy was developed and implemented. 

Patient flow is reviewed daily as a part of 

morning report. Morning and afternoon bed 

huddles are held to maximize patient flow. 

Y N 

EOC 

10. Correct IC vulnerabilities. Engineering checked the length of 

emergency call system cords in all patient 

bathrooms to ensure they are accessible from 

the floor and made of appropriate material. 

Engineering identified all patient rooms with 

overbed lights that used tape as pull cords. 

All were replaced with appropriate pull cords. 

Monitoring is performed on EOC rounds. 

Engineering contracted to install a centrally 

monitored patient care refrigerator and 

freezer system. Supervisors and managers 

were educated on manual monitoring. 

Ongoing monthly audits are conducted. Full 

implementation of the electronic monitoring 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

system is due by September 30, 2011. The 

EOC Committee will oversee and monitor the 

project. 

Engineering completed a project to ensure 

proper temperature and humidity control in 

medication storage rooms. 

Ongoing monitoring of patient care 

equipment, furniture, and storage areas is 

performed on EOC rounds. 

11. Correct safety vulnerabilities. Engineering replaced ceiling tiles and grids in 

locked psychiatric unit day rooms with solid 

ceilings. Ceiling panels in the locked 

psychiatric unit main hallways have plastic 

tabs to prevent access. 

Engineering replaced the shower control 

fixture in the women’s shower on one of the 

locked psychiatric units with an institutional 

fixture. 

Engineering replaced the nursing station door 

on a locked psychiatric unit with a ‘Dutch 

Door’ to reduce the risk of unauthorized entry. 

It was not feasible to correct the slope issue 

in individual showers. These showers are no 

longer used, and patients use the unit’s 

shower room. 

Ongoing monitoring of storage of medication, 

cleaning solutions, oxygen tanks, and 

Y N 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

equipment and emergency crash cart 

inspections are performed on EOC rounds. 

12. Correct patient privacy vulnerabilities. Privacy rounds frequency was increased. VA 

police round actively after business hours. 

White marker boards are no longer visible 

from the hallway. 

Y N 

13. Evaluate inpatient MH overflow, ensure 

proper unit designation, and complete 

environmental planning to assure patient 

safety. 

In June 2008, MH leadership reviewed 

admission practice patterns and developed 

criteria based on age and behaviors. In 

March 2010, a third acute MH unit was 

opened, reducing placement of general 

psychiatry patients on the geropsychiatry 

ward. Two general psychiatry units were 

renovated to enhance safety. The third unit is 

to be renovated prior to September 30, 2011. 

Y N 

Pharmacy Operations 

14. Conduct controlled substances 

inspections in accordance with VHA policy. 

The overall inspection compliance rate for 

FY 2010 was 99 percent. The overall 

compliance rate for FY 2011 is 100 percent. 

Y N 

15. Correct all indentified EOC findings within 

the pharmacy at the Jefferson Barracks 

division. 

Engineering replaced soiled ceiling tiles and 

sealed pharmacy ceiling penetrations. 

Ceiling vents and the identified unit were 

cleaned and repaired. Engineering reviewed 

the pharmacy floor finding; replacing the floor 

is unfeasible. A new building project will 

expand pharmacy space and eliminate the 

issue. Partial funding is expected in FY 2012 

with full funding expected in FY 2013. 

Y N 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

16. Correct the identified privacy concerns at 

the Jefferson Barracks division. 

A renovated room is used as a pharmacy 

patient waiting space, allowing separation of 

the combined waiting/consultation areas. 

Renovations will create additional 

consultation space. Three white noise 

generators were purchased and installed in 

the consultation and waiting rooms. 

Y N 

Follow-Up on Background Investigations 

and Security Clearances 

17. Comply with VHA employment screening 

requirements. 

The Human Resource manager developed a 

screening checklist, and it has been applied 

to all employees. The most recent revision 

occurred on May 27, 2010. 

Y N 

Follow-Up on Moderate Sedation Practices 

18. Document cardiopulmonary resuscitation 

training in the electronic training record, as 

required by facility policy. 

Training is recorded in the Talent 

Management System and tracked by the 

credentialing supervisor. 

Y N 

19. Document current training in airway 

management and cardiac arrhythmias for all 

providers privileged to administer moderate 

sedation. 

Documentation of training to administer 

moderate sedation is reviewed by the 

Professional Standards Board. 

Y N 

20. Privilege providers who administer 

moderate sedation in accordance with VHA 

policy. 

Moderate sedation privilege was 

standardized. A list of all providers with 

moderate sedation privileges is maintained by 

the credentialing supervisor and published to 

the services. 

Y N 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

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 48.4 43.6 45.3 43.2 49.4 50.5 45.8 49.0 

VISN 59.0 56.0 56.9 55.2 53.5 52.9 51.6 52.5 

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 15 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

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

conditions11 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 12.67 6.61 15.09 19.84 22.81 16.45 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

11 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. 

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CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 18, 2011
 

From: Director, VA Heartland Network (10N15)
 

Subject: CAP Review of the St. Louis VA Medical Center,
 

St. Louis, MO 

To:	 Director, Kansas City Office of Healthcare Inspections 

(54KC) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I have reviewed the findings and recommendations and concur. Our 

actions to the recommendations are attached. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 August 18, 2011 

From:	 Director, St. Louis VA Medical Center (657/00) 

Subject:	 CAP Review of the St. Louis VA Medical Center, 

St. Louis, MO 

To:	 VISN Director (10N15) 

1.	 I concur with the findings and recommendations presented in the 

St Louis VA Medical Center OIG Report. Implementation plans and 

target completion dates for each recommendation are included in the 

following pages. 

2.	 The Medical Center benefited from the thorough review of the 

operations, systems, and processes. It revalidated the quality and safe 

patient care that is provided to our Veterans. 

3.	 Questions or further comments regarding this response can be 

directed to me. 

Rimaann O. Nelson RN MPH/HAS 

Medical Center Director 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

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 committees responsible for moderate 

sedation, mortality review, and resuscitation events analyze aggregate QM data, 

document their discussion, and make recommendations based on the analysis. 

Concur 

Target date for completion: December 31, 2011 

The Chief, Quality Management will train chairs and recorders of committees 

responsible for review of QM data to ensure the documentation of discussion, analysis 

and recommendations based on the analysis. Minutes will be reviewed for compliance 

for 6 months by the Chief, Quality Management. Audit results will be reported to Quality 

Executive Board. 

Recommendation 2. We recommended that written requests for PR extensions be 

submitted to the facility Director and approved in writing prior to the 120-day deadline. 

Concur 

Target date for completion: June 30, 2011 

Risk Manager will continue to obtain written request for Peer Review extension from the 

Medical Center Director prior to the 120 day deadline. Number of extensions requested 

and granted prior to the 120 day deadline will be included in quarterly peer review report 

to the Medical Executive Board. 

Recommendation 3. We recommended that physicians complete the required training 

regarding medications used for moderate sedation. 

Concur 

Target date for completion: September 30, 2011 

As required by Medical Center Policy, physicians have completed required training 

regarding medication use for moderate sedation. This training was not consistently 

documented in the physician file. Training will be recorded in Talent Management 

System (TMS). Incumbents with moderation sedation privileges will record training in 

TMS by September 30, 2011. 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

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

all components of written AD notification and screening are provided to patients and 

documented in the medical record. 

Concur 

Target date for completion: September 30, 2011 

The Chief, Social Work will ensure staff received education of all components of written 

AD notification and screening procedures. Individuals with a role in the process will 

have training specific to the documentation requirements in the medical record. Chief, 

Social Work will audit medical records for compliance. Chief, Social Work will report 

compliance data to Clinical Executive Board. 

Recommendation 5. We recommended that facility policy be updated to include 

identification of the staff responsible for providing AD notification. 

Concur 

Target date for completion: September 30, 2011 

The Chief, Social Work will revise medical center policy to include identification of staff 

responsible for providing AD notification. 

Recommendation 6. We recommended that facility policies related to EN be updated 

to be consistent with VHA policy, that facility IC policy be revised to include EN IC 

expectations, and that compliance with the updated policies be monitored. 

Concur 

Target date for completion: September 30, 2011 

The Chief, Clinical Nutrition will lead an inter-disciplinary team to updated medical 

center policies related to EN to be consistent with VHA policy. Infection Prevention 

practices were reviewed and incorporated in the updated policies. An observation 

checklist was developed to monitor compliance with the revised policy. Chief, Clinical 

Nutrition will report compliance data to Clinical Executive Board. 

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

EN documentation includes all required elements. 

Concur 

Target date for completion: September 30, 2011 

The inter-disciplinary team reviewed and revised documentation templates associated 

with EN to include all required elements. Staff were trained on the new templates prior 

to use. Chief, Clinical Nutrition will conduct documentation audits to monitor 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

compliance. Chief, Clinical Nutrition will report compliance data to Clinical Executive 

Board. 

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

written instructions are provided to patients discharged with EN and that receipt is 

documented. 

Concur 

Target date for completion: September 30, 2011 

The inter-disciplinary team reviewed and revised written discharge instruction EN 

materials. Provision of EN written instructions will be documented in the medical 

record. Chief, Clinical Nutrition will conduct documentation audits to monitor 

compliance. Chief, Clinical Nutrition will report compliance data to Clinical Executive 

Board. 

Recommendation 9. We recommended that the established process for initial and 

ongoing RN competency assessment and validation be consistently followed. 

Concur 

Target date for completion: September 30, 2011 

The RN competency assessment process was established and fully implemented 

May 2011. This process included revision of medical center policy “Competency and 

Training Verification Program,” education of supervisors and staff, standardized forms, 

standardized layout of six part competency folder, with physical review of competency 

folders and content audit. Associate Chief Nurse for Education will report compliance 

data to Clinical Executive Board. 

Recommendation 10. We recommended that managers identify unit/position-specific 

RN competencies for all patient care areas that are consistent with the individual’s 

nursing assignment. 

Concur 

Target date for completion: August 31, 2011 

The Nurse Managers in collaboration with Nursing Instructors determined on-going 

competencies based on high risk, low volume, problem prone processes, procedures, 

and equipment, data, and identified needs from supervisors and staff. The on-going 

competencies are individualized to each unit/area of nursing practice. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Recommendation 11. We recommended that processes be strengthened to ensure 

that competency validation documentation is complete. 

Concur 

Target date for completion: August 31, 2011 

Medical Center Memorandum “Competency & Training Verification Program” identifies a 

standardized method to document competency verification. Training has been provided 

for each Nurse Manager on the standardized method for documenting competency 

verification. The competency folders will be audited for compliance by the Associate 

Nurse Executive for Education and reported to the Clinical Executive Board. 

Recommendation 12. We recommended that unit/position-specific competency 

validation documentation specify the methods used to assess and validate competency. 

Concur 

Target date for completion: August 31, 2011 

The method used to assess and validate competency was added for each unit/position 

specific competency. Associate Chief Nurse for Education will report compliance data 

to Clinical Executive Board. 

Recommendation 13. We recommended that a comprehensive workplace violence 

policy that includes a training plan be written and implemented. 

Concur 

Target date for completion: September 30, 2011 

Associate Chief of Staff for Mental Health Service developed a comprehensive 

workplace violence policy for medical center. A training plan was developed in 

accordance with the policy. Compliance will be monitor and reported to the Medical 

Executive Board. 

Recommendation 14. We recommended that annual N95 respirator fit testing be 

completed and that compliance be monitored. 

Concur 

Target date for completion: September 30, 2011 

The Safety Manager will ensure that N95 respirator fit testing is completed during new 

employee orientation and annually thereafter. The Safety Manager will monitor and 

reported compliance to the Administrative Executive Board through the Environment of 

Care Committee. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

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	 Dorothy Duncan, RN, MHA, Project Leader 

James Seitz, RN, MBA, Team Leader 

Jennifer Kubiak, RN, CPHQ 

Clarissa Reynolds, MBA 

Laura Tovar, LCSW 

Jennifer Whitehead, Program Support Assistant 

James Werner, Office of Investigations 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the St. Louis VA Medical Center, St. Louis, MO 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heartland Network (10N15) 

Director, St. Louis VA Medical Center (657/00) 

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: Roy Blunt, Richard J. Durbin, Mark Kirk, Claire McCaskill 

U.S. House of Representatives: Todd Akin; Russ Carnahan; William “Lacy” Clay, Jr.; 

Jerry Costello; Jo Ann Emerson; Blaine Luetkemeyer; John Shimkus 

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

VA OIG Office of Healthcare Inspections 24