Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections
 

Report No.11-00031-197

Combined Assessment Program
 

Review of the
 

Oklahoma City VA Medical Center
 

Oklahoma City, Oklahoma
 

June 10, 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 Oklahoma City VA Medical Center, Oklahoma City, OK 

Glossary

ACLS Advanced Cardiac Life Support 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CPR cardiopulmonary resuscitation 

CRC Cardiopulmonary Resuscitation Committee 

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

and Directives 

EOC environment of care 

facility Oklahoma City VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FY fiscal year 

IC infection control 

JC Joint Commission 

MDRO multidrug-resistant organisms 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

OSHA Occupational Safety and Health Administration 

PPE personal protective equipment 

QM quality management 

SOPs standard operating procedures 

SPICE Safety/Performance Improvement/Clinical Executive 

Committee 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Table of Contents
 

Page
 

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

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

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

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

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

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

Physician C&P................................................................................................... 2
 

COC .................................................................................................................. 3
 

Management of Test Results............................................................................. 4
 

Medication Management ................................................................................... 5
 

Management of MDRO...................................................................................... 6
 

EOC................................................................................................................... 6
 

QM..................................................................................................................... 7
 

Follow-Up on CPR and ACLS Training and Certification................................... 8
 

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

Appendixes

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

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

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

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 21
 

G. Report Distribution ............................................................................................ 22
 

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

Review of the Oklahoma City VA Medical Center,
 

Oklahoma City, OK
 

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 and one follow-up 

review area. 

Recommendations: We made 

recommendations in the following seven 

activities and follow-up review area: 

Physician Credentialing and Privileging: 

Initiate Focused Professional Practice 

Evaluations for all applicable physicians, 

and report results. Maintain adequate 

competency data in all physicians’ 

profiles. 

Coordination of Care: Provide and 

document advance directive notification 

and screening. Scan all advance 

directives into the electronic medical 

record, and link advance care planning 

notes to the clinical alert posting. 

Provide copies of completed advance 

directives to patients. 

Management of Test Results: Document 

the time critical results were 

communicated to ordering providers. 

Document notification and treatment 

actions for critical results. Communicate 

normal results to patients within the 

specified timeframe. 

Medication Management: Dispose of 

protective gowns worn during the 

hazardous drug compounding process 

immediately upon removal. Separate 

clean and dirty supplies during 

chemotherapy administration. 

Management of Multidrug-Resistant 

Organisms: Provide infection prevention 

strategies education to affected patients 

and their families, and document it. 

Educate employees annually, and 

document it. 

Environment of Care: Complete required 

training for designated employees, and 

document it. Develop a system to verify 

annual inspection of radiation shields 

and aprons. Secure patient information 

in the medical intensive care unit. 

Quality Management: Provide the 

required service-level medical record 

reviews, and include all required 

components. 

Follow-Up on Cardiopulmonary 

Resuscitation and Advanced Cardiac 

Life Support Training and Certification: 

Ensure required staff maintain current 

certification. 

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 Oklahoma City VA Medical Center, Oklahoma City, OK 

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 and follow-up review area: 

	 COC 

	 EOC 

	 Follow-Up on CPR and ACLS Training and 

Certification 

	 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 SOPs for CAP reviews. We also 

followed up on the recommendation from our prior CAP 

review of the facility (Combined Assessment Program 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK

VA OIG Office of Healthcare Inspections 2

Review of the Oklahoma City VA Medical Center,

Oklahoma City, Oklahoma, Report No. 08-01266-176,

August 1, 2008). (See Appendix B for further details.) The

facility had a repeat finding in CPR and ACLS training and

certification.

During this review, we also presented crime awareness

briefings for 385 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

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 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 areas that needed improvement.

FPPE. VHA requires that an FPPE be initiated for all

physicians who have been newly hired or have added new

privileges and that the Clinical Executive Committee review

recommendations.1 Only three of the five applicable

physicians whose profiles we reviewed had an FPPE

implemented. Only two of the three completed FPPEs were

reported to SPICE.

OPPE. VHA also requires that data consistent with

service-specific competency criteria be collected, maintained

in each physician’s profile, and reviewed on an ongoing

periodic basis. Only four of the eight applicable physician

profiles reviewed had evidence of data for the previous

4 quarterly OPPE periods.

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Recommendations& 1. We recommended that FPPEs be initiated for all 

applicable physicians and that results be reported to SPICE. 

2. We recommended that processes be strengthened to 

ensure that adequate competency data is maintained in all 

physicians’ profiles. 

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 14 patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We identified the following areas that needed 

improvement. 

Advance Directive Notification and Screening. VHA requires 

that patients be given written notification at each admission 

stating their right to accept or refuse medical treatment, to 

designate a Health Care Agent, and to document their 

treatment preferences in an advance directive.2 We found 

evidence of written notification in only 2 of the 14 medical 

records. 

VHA also requires that facility staff ask patients whether they 

have an advance directive and whether they want more 

information and/or assistance in completing the advance 

directive forms. We found evidence of screening in only 

11 of the 14 medical records. 

Management of Advance Directive Documents. VHA 

requires that advance directives be filed in patient medical 

records and that the patient receive a copy of the completed 

advance directive. Six of the 14 medical records indicated 

the presence of advance directives. Electronic copies of 

advance directives were present in four of the six records. 

Only one of the six records contained documentation that the 

patient received a copy of the completed advance directive. 

VHA also requires that staff use specific progress note titles 

when documenting advance care planning discussions with 

patients and link these notes to the CWAD postings in the 

electronic medical record. Advance directive notes were 

linked to CWAD postings in only 2 of the 14 medical records. 

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

references to VHA requirements in this section refer to this directive. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Recommendations
 

Management of

Test Results

3. We recommended that processes be strengthened to 

ensure that staff provide and document advance directive 

notification and screening at each inpatient admission. 

4. We recommended that processes be strengthened to 

ensure that all advance directives are scanned into the 

electronic medical record and that patient advance care 

planning progress notes are linked to the CWAD posting. 

5. We recommended that a copy of the completed advance 

directive document be provided to the patient. 

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

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.3 

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

reviewed medical records. We identified the following areas 

that needed improvement. 

Documentation of Ordering Provider Notification. VHA 

requires that diagnostic laboratory, radiology, and pathology 

clinicians document in the medical record the time and 

means of critical test result communication and the name of 

the ordering provider contacted.4 We reviewed the medical 

records of 30 patients who had critical results and found that 

diagnostic clinicians documented the time the ordering 

provider was notified in only 25 (83 percent) of the records. 

Documentation of Treatment Actions. VHA requires ordering 

providers to document in the medical record patient 

notification and treatment actions in response to critical test 

results. We reviewed the medical records of 30 patients who 

had critical results and found documented evidence of 

patient notification and follow-up actions in only 

25 (83 percent) of the records. 

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. We reviewed the medical 

records of 20 patients who had normal results and found that 

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

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

requirements in this section refer to this directive.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Recommendations
 

Medication

Management

Recommendations

only 13 of the records contained documented evidence that 

the facility had communicated the results to the patients. 

6. We recommended that diagnostic clinicians consistently 

document the time critical results were communicated to 

ordering providers. 

7. We recommended that ordering providers document 

patient notification and treatment actions in response to 

critical results. 

8. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

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 areas that needed 

improvement. 

PPE. The American Society of Health-System Pharmacists 

specifies that gowns worn during the compounding of 

hazardous drugs be disposed of immediately upon removal. 

Although pharmacy personnel wore protective gowns while 

compounding medications, the gowns were removed and 

hung on the wall of the compounding room for reuse during 

the day. 

Work Practice. The JC requires that facilities separate clean 

and dirty items. We observed that nursing staff placed dirty 

chemotherapy supplies in a containment bag with clean 

chemotherapy supplies. 

9. We recommended that protective gowns worn during the 

hazardous drug compounding process be disposed of 

immediately upon removal. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

10. We recommended that processes be strengthened to 

ensure that nursing staff who administer chemotherapy 

medications separate clean and dirty supplies during 

chemotherapy administration. 

Management of The purpose of this review was to evaluate whether the 

MDRO facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected two inpatient medical units and interviewed 

two employees. We identified no deficits in either the 

inspections or staff interviews. However, we identified the 

following areas that needed improvement. 

Patient/Family Education. The JC requires that patients 

infected or colonized5 with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of PPE. We reviewed 

27 medical records and found that only 14 of the records had 

documented evidence of MDRO education. 

Employee Training. The JC requires that facilities conduct a 

risk assessment to determine the need for staff education. 

The facility’s most recent risk assessment stated that staff 

education was indicated for all employees during orientation 

and annually thereafter. We reviewed 52 employee training 

records to determine whether MDRO education had been 

provided in accordance with the risk assessment. We found 

that only nine (17 percent) of the records reviewed had 

documentation of annual MDRO education. 

Recommendations& 11. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented. 

12. We recommended that employees receive annual 

MDRO education and that the training be consistently 

documented. 

EOC The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the surgical, medicine, medical intensive care, 

rehabilitation, and mental health units; the CLC; the 

5 Colonization is the presence of bacteria in the body without causing clinical infection. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Recommendations
 

emergency room; a primary care and an audiology clinic; 

nuclear medicine; and general and interventional radiology. 

The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement. 

IC. If facilities use N95 respirators, OSHA requires that 

designated employees are fit tested annually. We reviewed 

25 employee training records and determined that only 

17 designated employees had the required annual fit testing. 

Radiology. OSHA requires that the facility implement 

procedures for periodically inspecting the integrity of 

radiation shields and aprons. The facility does not maintain 

a master list of all aprons and shields; therefore, staff were 

unable to verify annual inspection of all aprons and shields. 

The Radiation Safety Officer requires radiation safety training 

annually. We reviewed five Radiology Service employee 

training records and determined that one had the required 

annual radiation safety training documented. 

Patient Privacy. The Health Insurance Portability and 

Accountability Act requires confidential patient information to 

be secured. We found unsecured patient information outside 

patient rooms on the medical intensive care unit. 

13. We recommended that annual N95 respirator fit testing 

and radiation safety training be completed by designated 

employees and documented. 

14. We recommended that a system be developed to verify 

annual inspection of radiation shields and aprons. 

15. We recommended that processes be strengthened to 

ensure that confidential patient information in the medical 

intensive care unit is secured. 

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. 

VA OIG Office of Healthcare Inspections 7 

QM
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

VHA requires that each facility have a policy mandating the 

membership and responsibilities of a CRC or its equivalent.6 

The facility had a CRC but no policy until March 3, 2011. We 

found the policy acceptable; therefore, we made no 

recommendation. However, we identified the following area 

that needed improvement. 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include specific areas of review.7 

We found that two services did not provide the required 

medical record reviews and that medical record reviews did 

not include all of the required components. For example, we 

found that until February 2011, the facility did not review 

outpatient encounter notes, progress notes, or progress note 

addendums. 

Recommendation& 16. We recommended that all services provide the required 

medical record reviews and that processes be strengthened 

to ensure that all required components are included. 

Follow-Up on CPR

and ACLS Training

and Certification

As a follow-up to a recommendation from our prior CAP 

review, we reassessed facility compliance with CPR and 

ACLS certification for clinically active staff. The facility had 

implemented a tracking system to monitor CPR and ACLS 

certifications, and status reports were forwarded to the 

appropriate service chiefs for action. Although, monitoring 

for staff compliance with certifications occurred monthly, the 

facility failed to ensure staff maintained current certifications. 

During the past year, compliance was below acceptable 

levels; however, when we were onsite, the facility reported 

current compliance at approximately 96 percent. 

Recommendation& 17. We recommended that clinically active staff maintain 

current CPR and/or ACLS certification. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 13–20, for the full text of the Directors’ comments.) We consider 

Recommendations 1, 6, 9, 10, 11, 15, and 16 closed. We will follow up on the planned 

actions for the open recommendations until they are completed. 

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

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 7 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Appendix A

Facility Profile8

Type of Organization Tertiary care medical center 

Complexity Level 1b 

VISN 16 

Community Based Outpatient Clinics Altus, OK 

Ardmore, OK 

Blackwell, OK 

Enid, OK 

Konawa, OK 

Lawton, OK 

Wichita Falls, OK 

Veteran Population in Catchment Area 199,244 (FY 2011 projected) 

Type and Number of Total Operating Beds:

 Hospital, including Psychosocial

Residential Rehabilitation Treatment

Program

159 

 CLC/Nursing Home Care Unit 33 

 Other 0 

Medical School Affiliation(s) University of Oklahoma College of Medicine 

 Number of Residents 105 

Resources (in millions):

 Total Medical Care Budget

Current FY (through

December 2010)

$375 

Prior FY (2010)

$398 

 Medical Care Expenditures $100 $398 

Total Medical Care Full-Time Employee

Equivalents

Workload:

 Number of Station Level Unique

Patients

 Inpatient Days of Care:

o Acute Care

1,734.9 

34,312 

11,056 

1,724.8 

55,383 

45,794 

o CLC/Nursing Home Care Unit 2,120 8,569 

Hospital Discharges 1,572 6,556 

Total Average Daily Census (including all bed

types)

147.1 152.2 

Cumulative Occupancy Rate (in percent) 76.6 79.3 

Outpatient Visits 118,498 504,277 

8 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Appendix B

Follow-Up on Previous Recommendation

Recommendation Current Status of Corrective Actions

Taken

In Compliance

Y/N

Repeat

Recommendation?

Y/N

QM

1. Ensure clinically active staff have CPR or 

ACLS training and current certification. 

Compliance fell below acceptable 

levels during the past year; however, 

for March 2011 compliance was at 

approximately 96 percent. 

N Y (see page 8) 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

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 62.0 67.7 56.9 64.7 39.7 47.3 47.5 43.6 

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 11 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

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

conditions9 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 13.79 8.73 16.96 20.11 21.08 16.98 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

9 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 12 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Appendix D

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: April 21, 2011 

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

Subject: CAP Review of the Oklahoma City VA Medical Center,

Oklahoma City, OK

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

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

1.	 The South Central VA Health Care Network (VISN 16) has reviewed 

the response from the Oklahoma City VA Medical Center and concurs 

with the response. 

2.	 If you have any questions, please contact Adrienne Riesenbeck, 

Director, Office of Performance and Quality, at (405) 456-3146. 

(original signed by:) 

George H. Gray, Jr. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Appendix E

Facility Director Comments

Department of

Veterans Affairs Memorandum

Date: April 21, 2011 

From: Director, Oklahoma City VA Medical Center (635/00) 

Subject: CAP Review of the Oklahoma City VA Medical Center,

Oklahoma City, OK

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

1.	 We appreciate the opportunity to work with the Office of Inspector 

General as we continuously strive to improve the quality of healthcare 

for America’s Veterans. 

2.	 I concur with the finding and recommendation of the OIG CAP Survey 

Team. The importance of this review is acknowledged as we 

continually strive to provide the best possible care. 

3.	 If you have any questions, please contact Adrienne Riesenbeck, 

Director, Office of Performance and Quality, at (405) 456-3146. 

(original signed by:) 

David P. Wood, MHA, FACHE 

Oklahoma City VAMC Director 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

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 FPPEs be initiated for all applicable 

physicians and that results be reported to SPICE. 

Concur

Target date for completion: Complete

FPPE requests are initiated through the Credentialing Committee (PSB) for all 

applicable physicians, dentists, and mid-level providers. A tracking mechanism will be 

utilized to ensure all FPPE results are reported back to the Credentialing Committee 

and the Medical Staff Executive Committee (SPICE) as initially requested by the 

committee. FPPE was completed as appropriate for the staff identified as noncompliant 

by the OIG review team. The FPPE was reported to the SPICE Committee by 

April 21, 2011. 

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

adequate competency data is maintained in all physicians’ profiles. 

Concur

Target date for completion: July 1, 2011

OPPE criteria and data will be reviewed by the Credentialing Committee (PSB) to 

ensure adequate data is maintained in all physicians’ profiles. The OPPE data will then 

be reviewed by the SPICE Committee with actions taken as appropriate. 

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

staff provide and document advance directive notification and screening at each 

inpatient admission. 

Concur

Target date for completion: June 30, 2011

Following the OIG visit, a workgroup was convened by the Chief of Staff to ensure the 

facility’s advance directive process is congruent with VA requirements. The workgroup 

will develop processes to ensure staff provide and document advance directive 

notification and screening at each inpatient admission. Random chart reviews will be 

completed and reported to the Safety and Performance Improvement Clinical Executive 

Committee. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

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

all advance directives are scanned into the electronic medical record and that patient 

advance care planning progress notes are linked to the CWAD posting. 

Concur

Target date for completion: June 30, 2011

Following the OIG visit, a workgroup was convened by the Chief of Staff to ensure the 

facility’s advance directive process is congruent with VA requirements. The workgroup 

will develop processes to ensure all advance directives are scanned into the medical 

record and the patient advance care planning progress notes are linked to the CWAD 

posting. Random chart reviews will be completed and reported to the Safety and 

Performance Improvement Clinical Executive Committee. 

Recommendation 5. We recommended that a copy of the completed advance 

directive document be provided to the patient. 

Concur

Target date for completion: June 30, 2011

Following the OIG visit, a workgroup was convened by the Chief of Staff to ensure the 

facility’s advance directive process is congruent with VA requirements. The workgroup 

will develop processes to ensure a copy of the completed advance directive document 

is provided to the patient. Random chart reviews will be completed and reported to the 

Safety and Performance Improvement Clinical Executive Committee. 

Recommendation 6. We recommended that diagnostic clinicians consistently 

document the time critical results were communicated to ordering providers. 

Concur

Target date for completion: Complete

Immediately following the OIG review, staff were re-educated on the reporting of crticial 

test results to the provider. Facility specified critical results were also reviewed with the 

lab staff. A random review of critical test results will be conducted to ensure the time 

critical results were communicated to the provider is documented. Compliance rate will 

be reported to the Patient Safety Goals Committee. 

Recommendation 7. We recommended that ordering providers document patient 

notification and treatment actions in response to critical results. 

Concur

Target date for completion: June 30, 2011

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

A taskgroup was convened to address documentation of patient notification and 

treatment actions in response to critical results. Random chart reviews will be 

conducted to monitor compliance. 

Recommendation 8. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur

Target date for completion: June 30, 2011

A taskgroup was convened to address the timely notification of normal test results in 

accordance with VA requirements. The notification will be documented in the medical 

record. Random chart reviews will be conducted to monitor compliance. 

Recommendation 9. We recommended that protective gowns worn during the 

hazardous drug compounding process be disposed of immediately upon removal. 

Concur

Target date for completion: Complete

The Pharmacy standard operating procedure (SOP) was revised to include “gown is to 

be discarded when removed.” Pharmacy staff responsible for compounding 

chemotherapeutic agents were educated on the revised SOP at the Pharmacy Service 

Staff Meeting on March 23, 2011. Random observations will be conducted to ensure 

staff are compliant with the revised SOP requirements. 

Recommendation 10. We recommended that processes be strengthened to ensure 

that nursing staff who administer chemotherapy medications separate clean and dirty 

supplies during chemotherapy administration. 

Concur

Target date for completion: Complete

Following the OIG review, a process was put in place to have a second bag supplied 

with chemotherapeutic agents. The used chemotherapy bag will be placed in the bag, 

which is labeled as “chemotherapy,” and disposed of appropriately. NM/designee will 

randomly monitor compliance to ensure clean and dirty supplies are kept separate 

during chemotherapy administration. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Recommendation 11. We recommended that infection prevention strategies education 

be provided to patients infected or colonized with MDRO and their families and be 

documented. 

Concur

Target date for completion: Complete

Staff nurses were re-educated by April 5, 2011 regarding the need to provide and 

document MDRO patient education. Nurse Managers are completing random 

monitoring of documentation of MDRO education with immediate follow-up provided as 

appropriate. The rate of compliance with documentation of education will be reported 

by the MDRO Prevention Coordinator to the Patient Safety Goals Committee, the 

Infection Control Committee, and Nursing Leadership. 

Recommendation 12. We recommended that employees receive annual MDRO 

education and that the training be consistently documented. 

Concur

Target date for completion: August 31, 2011

All staff reviewed by the OIG review team for MDRO education now have 

documentation of required education. All service chiefs were notified of the 

requirements for annual MDRO staff education on March 7, 2011. Service chiefs are 

required to report the rate of compliance with annual MDRO staff education, and the 

rate of compliance is reported to Infection Control Committee and rolled up to SPICE 

Committee. The current compliance rate is 95%. 

Recommendation 13. We recommended that annual N95 respirator fit testing and 

radiation safety training be completed by designated employees and documented. 

Concur

Target date for completion: August 31, 2011

All staff reviewed by the OIG for N95 respirator fit testing are now compliant. A process 

was developed to ensure staff and service chiefs are notified of the requirement for 

N95 respirator fit testing. New personnel will be fit tested on entry to the facility. The 

compliance rate for N95 respirator fit testing will be reported monthly to the EOC 

Committee. Fit testing for the required staff is ongoing. The facility compliance rate is 

currently 82%. Completion of fit testing for required staff is expected by 

August 31, 2011. Radiation Safety Training has been completed for 100% of radiology 

staff. A process was developed to ensure staff and service chiefs are notified of the 

annual requirement for Radiation Safety Training. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Recommendation 14. We recommended that a system be developed to verify annual 

inspection of radiation shields and aprons. 

Concur

Target date for completion: June 30, 2011

An inventory of all services utilizing lead aprons in underway. A master list of all lead 

aprons will be developed, and will be utilized to ensure all lead aprons are inspected 

annually. In addition, local policy will be updated to require the Physical Science 

Technician’s signature approval prior to the purchase of any lead aprons, and disposal 

of lead aprons can only be done by the Physical Science Technician. The master list 

will then be updated to include lead aprons purchased and destroyed. 

Recommendation 15. We recommended that processes be strengthened to ensure 

that confidential patient information in the medical intensive care unit is secured. 

Concur

Target date for completion: Complete

Notebooks containing confidential patient information are now kept at the nurses’ 

station. The Nurse Manager or designee will conduct random observations to ensure 

patient confidential information is kept in a secure location. Privacy issues are also 

assessed and addressed during weekly EOC rounds. 

Recommendation 16. We recommended that all services provide the required medical 

record reviews and that processes be strengthened to ensure that all required 

components are included. 

Concur

Target date for completion: Complete

The two services requiring reporting of medical record reviews reported medical record 

reviews to the Medical Records Committee on April 14, 2011. Services that do not 

report medical record reviews to Medical Records Committee are reported to the 

Medical Executive Committee (SPICE Committee). The SPICE Committee chair will 

ensure reviews are submitted to Medical Records Committee. 

Recommendation 17. We recommended that clinically active staff maintain current 

CPR and/or ACLS certification. 

Concur

Target date for completion: August 31, 2011

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

Local facility policy was updated to include consequences for staff who do not 

obtain/maintain their certification. Monitoring of the completion of ACLS/BLS 

certification with compliance rate reported to the CPR Committee and Medical Center 

Leadership. The facility compliance rate is currently 96%. 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

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, RN, Project Leader 

Larry Ross, MS, Team Leader 

Myra Conway, RN 

Gayle Karamanos, PA 

Maureen Washburn, RN 

Misti Kincaid, BS, Program Support Assistant 

Steven Brezette, Dallas Office of Investigations 

Rachel Malone, Dallas Office of Investigations 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the Oklahoma City VA Medical Center, Oklahoma City, OK 

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, Oklahoma City VA Medical Center (635/00) 

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: Tom Coburn, James M. Inhofe 

U.S. House of Representatives: Tom Cole, James Lankford, Frank Lucas 

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

VA OIG Office of Healthcare Inspections 22